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Client Medical - History Consent For Name: Date of Birth: Age: Date Cell Ph: E-Mail: Address: Street City State Zip Code Procedure: Procedure Fee $ Consultation Fee $ Practitioner makes no attempt to, or claim to,practice medicine. Some individuals will have complications related to permanent makeup application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. If you are healthy, Not pregnant/or nursing, Have no previous tattoo and there are no visible reasons restricting you from receiving a tattoo, you must approve of the design and color before the application of your permanent makeup. To avoid unforeseen complications, please answer the following questions: ❑ Are you over the age of 18? If not,parent or guardian must sign this form for consent. ❑ Have you had any alcohol within the last 24 hours? ❑ Have you had any aspirin or blood thinning products within the last 7 days? ❑ Any mood altering drugs within the last 8 hours (Xanax,Prozac,Wellbutrin) etc... ❑ Do you take prescription drugs? ❑ Do you have any history of cold sores, herpes or fever blisters at the procedure cite? ❑ Are you sensitive or allergic to latex? ❑ Do you have problems with healing? Do you scar easily? ❑ Do you bleed easily from minor skin injuries? ❑ Previous problems with tattoos or has your physician advised you not to have a tattoo at this time? ❑ Are you allergic to any metal? (Can you only wear 14k gold?) ❑ Have you ever had any permanent makeup procedures before, prior to coming to Are you allergic to topical antibiotic numbing creams? Cl Are you pregnant or nursing? ❑ Are you required to take antibiotics during dental or invasive medical procedures? ❑ Do you have any drug allergies? If yes, Please print in the space provided below ❑ Are you currently taking medication for high or low blood pressure? ❑ Do you intentionally tan-direct sun or tanning bed? ❑ Have you experienced Hepatitis or Jaundice during the past 12 months? ❑ Do you have a history of diabetes? ❑ Do you have a history of allergic reactions to antibiotics? ❑ Do you have a history of hemophilia or other bleeding disorders? ❑ Do you a have history or cardiac valve disease? ❑ Are you taking any current medications? ❑ Do you have any other risk factors for bloodborne pathogens? If you are checking off the box(es) above, It does not indicate you are not an acceptable candidate for permanent cosmetics. It may simply be information that is valuable to your technician as each person's body is unique, or it may indicate that based on health conditions that affects healing, it would be advisable or required