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TANTRA I N K <br /> HOUSE OF PERMANENT MAKEUP w> I <br /> GENERAL INFORMATION <br /> Full Name DOB <br /> Address <br /> Contact Number _ Email <br /> What is your gender? 0 Male 0 Female Non-binary Other <br /> Are you 18 years of age or over? C Yes No <br /> How did you hear about us? <br /> PERSONAL HEALTH HISTORY <br /> Is this the first time receiving permanent makeup? 0 Yes 0 No <br /> If no,when/where was your last treatment <br /> Please indicate any of the following treatments you have had in the past year: <br /> 0 Skin grafts 0 Laser resurfacing 0 Alpha hydroxyl <br /> 0 Hair removal procedures 0 Chemical Peel 0 RetinA <br /> 0 Botox 0 AHA/BHA 0 Other <br /> When was your last treatment? <br /> Do you have a history of any of the following medical conditions: <br /> 0 Alcoholism 0 Epilepsy 0 HIV Positive <br /> 0 Alopecia 0 Eczema 0 Keloid Scarring <br /> 0 Autoimmune Disorder 0 Fainting Episodes 0 Liver Disease <br /> 0 Blisters/Herpes Simplex 0 Fever 0 MRSA <br /> 0 Bleeding Disorders 0 Forehead/Brow Lift 0 Organ Transplant <br /> 0 Cancer 0 Face Lift 0 Shingles <br /> 0 Chemotherapy/Radiation 0 Hemophilia 0 Skin Conditions <br /> O Diabetes 0 Other Bleeding disorders 0 Thyroid Issues <br /> O Dermatitis 0 Heart Condition 0 Tumours,Growths or Cysts <br /> O Easy Bleeding 0 Hepatitis (A,B,C,D) 0 Herpes at the Procedure <br /> 0 Cardiac Valve Disease 0 High Blood Pressure Site <br /> If other, please detail <br /> When was your last treatment? <br /> Have you had any history of allergic reactions to any of the following? <br /> Lidocaine (Anesthetic) Iron Oxide (-; Eggs O Latex O Antibiotics <br /> ©209-601-1326 (] TANTRAINK(c)YAHOO.CON4 �'&TANTRAINKAPM <br />