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Have you or have you ever had any of the following?Tick all of the following that apply: <br /> ❑ Abnormal Heart Condition ❑ Cold Sores (herpes simplex) <br /> ❑ Mitral Valve Prolapse ❑ Heart Murmur <br /> ❑ Rheumatic Fever ❑ Artificial Heart Valves <br /> ❑ Pacemaker ❑ Anaemia <br /> ❑ Haemophilia ❑ Prolonged Bleeding <br /> ❑ Diabetes ❑ High Blood Pressure <br /> ❑ Epilepsy ❑ Low Blood Pressure <br /> ❑ Fainting Spells or Dizziness ❑ Circulatory Problems <br /> ❑ Thyroid Disturbances ❑ Liver Disease <br /> ❑ Glaucoma ❑ Kidney Disease <br /> ❑ Stomach Ulcers ❑ Tumours, Growths or Cysts <br /> ❑ Cancer ❑ HIV <br /> ❑ Tuberculosis ❑ Prosthetic Hip or Joint <br /> ❑ Stroke ❑ Cataracts <br /> ❑ Palpitations ❑ Blurred Vision <br /> ❑ Hepatitis ❑ Dry Eyes <br /> ❑ Pregnant or Nursing in the 12 months ❑ Eye Infection present <br /> ❑ Alopecia ❑ Watery Eyes <br /> ❑ Recent Hair Loss ❑ Contact Lenses <br /> ❑ Chapped Lips ❑ Eyelid Surgery <br /> ❑ Trichotillomania ❑ Date of last eyelash/ eyebrow tint <br /> What would you like to improve about your eyebrows and/or lash line? Consider shape, color, density, <br /> thickness... <br /> Please read the following statements carefully. Permanent makeup is a way of cosmetic tattooing, intended to be <br /> semipermanent lasting average 12-18 months. On a rare occasion,the pigment may migrate under the skin.Procedure of <br /> microblading and/or permanent makeup may be uncomfortable.Although extremely rare,there might be an immediate or <br /> delayed allergic reaction to pigment.A negative patch test result does not guarantee that you will not develop an allergic <br /> reaction after the full procedure.Allergic reactions to anesthetic can occur.Permanent cosmetics cannot be performed <br /> if you are pregnant or nursing,or anyone under the age of 18.Infections can occur if aftercare instructions are not <br /> followed correctly.There may be swelling and redness following the procedure.You may experience minor bleeding.If you <br /> have an MRI scan within 3 months after your procedure,you should notify/discuss with your doctor.Possible scarring may <br /> occur. <br /> The information I have provided about my medical history is accurate to the best of my knowledge.I agree to <br /> accept responsibility for omissions regarding my failure to disclose any existing or past health conditions. <br /> Date: <br /> Client Name (Printed) <br /> Client Signature <br /> Therapist Signature <br />