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