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Are you allergic to any topical antibiotic preparations? Yes No <br /> Have you ever had a cold sore? Yes No <br /> Do you have any other medical or skin conditions that may affect the outcome of your <br /> procedure? <br /> Yes No <br /> If yes,please explain: <br /> Do you use any medications that might affect the healing of the body art you wish to receive? <br /> YES NO <br /> Is there any other information you feel you should provide to the body art practitioner? <br /> YES NO <br /> If yes, please explain: <br /> PLEASE READ AND INITIAL: <br /> I'm not pregnant and I consult with my doctor prior to my procedure. <br /> I'm 18 years or older. <br /> Prior to the procedure, I will give Lieu Nguyen my approval and will accept <br /> responsibility for pigment color and position of all permanent make-up on my eyebrows, <br /> eyeliner, lips and other areas. <br /> I have read and understand the nature, risk, and possible complications of permanent <br /> skin pigmentation. <br /> I understand the permanent skin pigmentation procedure carries with it known and <br /> unknown complications and consequences associated with this type if cosmetic procedure, <br /> including but not limited to infection, allergic reaction, scarring, inconsistent•color, and <br /> spreading, fanning, or fading pigments. <br />