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18 . 1 understand that photos taken before, during, and <br /> after your enhancement may be posted by Channda' s Brow Studio and <br /> by us only. (For marketing purposes your pictures may appear on <br /> our social media pages. ) <br /> 19. 1 understand that it is my responsibility to book <br /> my touch up accordingly to the timeframe and each touch up' s fee <br /> is accordingly to the timeframe. <br /> ACCEPTANCE: I have read and understand these risks listed above <br /> and they have been explained me. I DID NOT JUST SIGN THIS <br /> DOCUMENT I certify that the information in the above <br /> questionnaire is accurate and that it has been explained to me <br /> and my questions have been answered. I accept full responsibility <br /> for any complications that may arise or result during or <br /> following the cosmetic procedure (s) to be performed my request <br /> Signature of Client: Date: <br /> Signature of Technician: <br /> Date: <br /> Medical Information: <br /> CIRCLE YES OR NO <br /> — Do you have a history of herpes infection at the proposed <br /> site? (I .E. cold sores) Y/ N <br /> — Are you pregnant or nursing? Y/ N <br /> — Do you wear contact lenses? Y/ N <br /> — Do you have glaucoma or other eye disease, disorder or had any <br /> EYE trauma? Y/ N <br /> — DO YOU have epilepsy, hemophilia or other bleeding disorders? <br /> Y/ N <br /> — Have you had a vision correction procedure such Lasik surgery <br /> in the last 3 months? Y/ N <br /> — Are you considering having vision correction procedure in the <br /> next 2 months? Y/ N <br /> — Are you prone to eye infections (conjunctivitis/pink eye) ? <br /> Y/ N <br /> — Are you on a blood thinning medication? Y/ N <br /> — Do you take aspirin? Y / N Do you smoke? Y / N Drink alcohol? <br /> Y/ N <br /> — Are You on Accutane? OR have You taken it within the last <br /> year? Y/ N <br /> — Do you have cardiac valve disease? Y/ N <br /> — Do you suffer from any heart conditions? Y/ N <br /> — Prior to dental or surgical procedures, do you receive <br /> antibiotic therapy? Y/ N <br /> — Are you on steroids or anti-inflammatory medications? Y/ <br /> N <br /> — Do you suffer from Hepatitis, or other risk factors for blood <br /> borne pathogen exposure or any communicable disease? Y/ N <br /> — Do you have diabetes and use insulin? Y/ N <br /> — Do you suffer from a medical or skin condition such as: <br /> Keloids or hypertrophic scarring, psoriasis (at the procedure <br /> 3 <br />