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Permanent Makeup qm'r <br /> Consultation Form em 40 <br /> Email/Newsletter Appointment date Appointment time 00 <br /> @ Personal Information <br /> Would you like to be added to our FULL NAME <br /> subscriber list in order to receive <br /> information about upcoming D.O.B. AGE: PHONE#: <br /> discounts,promotions,contests <br /> etc? ADDRESS: <br /> Yes,subscribe me! To perform the Permanent Makeup procedure in a safe manner, please answer <br /> the following health questions truthfully.We will keep all information disclosed in <br /> a confidential manner and will use it only for purposes of determining whether <br /> No,thanks you are an ideal candidate for this procedure. <br /> Is it your first permanent makeup experience? CONTRAINDICATIONS: <br /> ❑Yes ❑No circle if applicable <br /> If no,what kind of permanent makeup did you do? <br /> ❑ Microblading ❑ Eyeliner ❑ Lip blushing ' Liver disease-high risk of <br /> infection <br /> How did you hear about us? ❑ Pregnancy/Nursing <br /> Are you currently wearing lash extensions of any kind? <br /> Compromised skin near <br /> ❑Yes ❑No brow/eye area <br /> MEDICAL INFORMATION _ Chemotherapy/Radiation <br /> Have you taken any of the following in the last 2 days;Aspirin, Skin conditions like <br /> psoriasis,dermatitis,active <br /> Ibuprofen,Coumadin,Alcohol? herpes outbreak,etc.near <br /> ❑No ❑Yes Specify......_._. W. the brow/eye area <br /> Have you received chemotherapy or radiation treatment in the last year? Retinoid/AHA/BHA within <br /> F7 last two weeks <br /> When? <br /> Blood-thinning <br /> No ❑Yes Specify......... �_.. ......_...___.. __._. _ _..._ <br /> !—!medications/substances or <br /> List any medications you have been taking in the last 6 months `plasma donation within 7 <br /> days <br /> _.............._................_.__...._.__............._....__............................_.._..._..._........_..........._..._.._..._...._. ___ .. ___.._ Lash extensions <br /> (permanent eyeliner only) <br /> Have you ever had an allergic reaction to any of the following(please circle): <br /> • Latex •Vaseline • Lidocaine • Foods • Metals <br /> • Lanolin • Medication • Paints • Crayons • Hair Dyes <br /> Other allergies (list) <br /> Anaesthetics or Adrenaline(which ones) <br />