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Allergies to metals, food, etc., <br />Do You use facial care treatments? - <br />History of herpes infection at the procerh re site? <br />History of allergic reactions to latex? <br />I' <br />History of allergic reactions to solibmtic ? <br />History of hemophilia or other bleeding isorders? <br />HrstprY of cardiac valve disease? <br />Any.: other blood borne pathogen risk fac rs? <br />Please list down any medications yot� are taking: <br />Do you take antibiotics prior to surge�y or dental procedures? <br />CONSENT ! certify that I am over the age oft ,and not under the influence of drugs or alcohol, and I consent to <br />receiving the Lip Blush procedure. I have been informed and it was explained tome 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 th at there might becomplications and consequences associated with <br />this procedure, such as: infection, scarring, ori consistent color. I understand that this cosmetic procedure is not <br />fully permanent and might result to fading in tiry e. 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 pate i test to identify any allergic reaction to any medicine or anesthetics. <br />Should I waive for the test, I release the techni ian from liability if I develop an allergic reaction to any of the <br />procedure. I acknowledge that some changes r iight not be corrected in case I undergo other laser hair removal, <br />plastic surger� or other procedures. I understa id that photographs taken for comparison of the before and after <br />procedure are part of the said procedure. I ace pt full responsibility for the decision to have this Lip Blush procedure <br />done. The cost for touch-ups after this first proc edure are not included. <br />Signature: <br />f` <br />r <br />C <br />f" <br />Do you take antibiotics prior to surge�y or dental procedures? <br />CONSENT ! certify that I am over the age oft ,and not under the influence of drugs or alcohol, and I consent to <br />receiving the Lip Blush procedure. I have been informed and it was explained tome 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 th at there might becomplications and consequences associated with <br />this procedure, such as: infection, scarring, ori consistent color. I understand that this cosmetic procedure is not <br />fully permanent and might result to fading in tiry e. 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 pate i test to identify any allergic reaction to any medicine or anesthetics. <br />Should I waive for the test, I release the techni ian from liability if I develop an allergic reaction to any of the <br />procedure. I acknowledge that some changes r iight not be corrected in case I undergo other laser hair removal, <br />plastic surger� or other procedures. I understa id that photographs taken for comparison of the before and after <br />procedure are part of the said procedure. I ace pt full responsibility for the decision to have this Lip Blush procedure <br />done. The cost for touch-ups after this first proc edure are not included. <br />Signature: <br />