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Permanent Cosmetics by Kristen Cranford <br /> Please print: <br /> 401 West Pine Street Lodi,California 95240 <br /> i <br /> Name Patcof Birth <br /> Address <br /> City Zip <br /> Phone Number Email <br /> List medications taken in last 6 months: <br /> Are you pregnant or nursing? Y N ___ <br /> Have you had: Chemotherapy or radiation in the past year? Y_ NChemical or laser peel in the last 6 <br /> weeks? Y_ N_ ANA preparations in the last 2 weeks? Y_ N— " <br /> w <br /> Do you: Bruise or bleed easily? Y_ N_ Scar easily? v_ N_ Have hypertrophic scars Y_ N_ ; <br /> Healing problems Y_ N_ Have keloid scars Y_ N_ <br /> Please circle any that apply: i <br /> I have had: Alopecia Anemia Clotting Issues Heart Disease Artificial Heart Valves Cancer <br /> Circulatory Problems Diabetes Epilepsy Fainting Spells or Dizziness Hair Loss Hepatitis <br /> Hemophilia or Other Bleeding Disorders Herpes at Procedure Site High or Low Blood Pressure <br /> HIV Liver disease Thyroid Disturbances Latex Allergy Allergic reaction to antibiotics <br /> Trichotillomania Tumors,Growths,or Cysts Sensitivity to Cosmetics Cardiac Valve Disease <br /> Requirements for antibiotics prior to surgery or dental procedures <br /> Other risk factors for Bloodborne Pathogens <br /> What are your expectations from this procedure? <br /> Microblading and Permanent Cosmetics is a form of tattooing. You might be slightly un,zomfortable,and there <br /> may be some swelling, redness, and minor bleeding. Allow your technician to judge whether to proceed or <br /> terminate process. After a healing period of approximately 4 weeks, touch up procedures may be performed. <br /> The pigment will initially be darker than expected, but will begin to fade immediately. On rare occasions,there <br /> may be an allergic reaction to pigment and/or anesthetic. (A patch test will not guarantee absence of allergic <br /> reaction.) Very uncommon, but possible, is pigment migration. Infections can occur if aftercare instructions are <br /> not followed correctly. Microblading and Permanent Make Up cannot be used on pregnant or nursing women, <br /> on oily skin, or anyone under 18. Seek medical attention for excessive swelling, inflammation, or discharge. <br /> Questions? Ask your technician. pigments <br /> am aware of the permanent nature of this procedure. (please initial) 1 am aware that the <br /> used are not FDA approved and health consequences are unknown. (please initial) I fully understand <br /> the information provided above,and havereceived information. I confirm that all of the information � <br /> provided by me is correct and truthful. Please Sign and date below. <br />