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Do you use facial care treatments? <br />Hislory of herpes? <br />History of allergic reactions to latex? I C` <br />History <br />of allergic reactions to antibioti <br />? <br />History <br />of hemophilia or other bleedinglisorderO <br />r <br />History of cardiac valve disease? fi fw. <br />Any other blood borne pathogenrisk factors? t` � <br />Please list down any medications you are tatting: <br />Do you take antibiotic's prior to surgery or dental procedures? <br />CONSENT I certify that I am over the age of 18, and not under the influence of drugs or alcohol, and I consent to <br />receivinU the Lip Blush procedure. I have been informed and it was explained to me the general nature of cosmetic <br />tattooing as well as the specific procedure to be performed. I have been informed of the possible risks and <br />consequences of Lip Blush and I understand that there might be complications and consequences associated with <br />this procedure, such as: infection, scarring, or inconsistent color. I understand that this cosmetic procedure is not <br />fully permanent and might result to fading in time. I have likewise received and will strictly adhere to procedural <br />instructions given to me. Any adverse effects due to my failure to adhere to the instructions shall solely be my <br />responsibility. I have been advised to do a path test to identify any allergic reaction to any medicine or anesthetics. <br />Should I waive for the test, I release the technician from liability if I develop an allergic reaction to any of the <br />procedure. I acknowledge that some changes might not be corrected in case I undergo other laser hair removal, <br />plastic surgery or other procedures. I understand that photographs taken for comparison of the before and after <br />procedure are part of the said procedure. I accept full responsibility for the decision to have this Lip Blush procedure <br />done. The cost for touch-up's after this first procedure are not included. <br />