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Initial I understand that it is my responsibility to book my touchup accordingly to the timeframe <br />and each touch up fee is according to the time frame. <br />Initial I understand there are NO guarantees and refunds will NOT be given. <br />Initial I acknowledge that tattoo inks, dyes, pigments have not been approved by the Federal Food <br />and Drug Administration (FDA). <br />***I have read and understand these risks listed above and they have been explained to me. I have <br />answered the questionnaire accurately and that it has been explained to me, I accept full responsibility <br />for any complications that may arise during or following the cosmetic procedure(s) to be performed at <br />my request. <br />Signature <br />Medical History <br />Are you pregnant or nursing? YES / NO <br />Do you have epilepsy, hemophilia, anemia, iron deficiency, or any bleeding disorders? YES / NO If yes, <br />what disorder? <br />Do you have diabetes and use insulin? YES / NO <br />Do you smoke? Drinl< alcohol? SMOKE /DRINK /NONE <br />Are you on Accutane? Or have you taken in within the last year? YES / NO <br />Do you have cardiac valve disease? Suffer from any heart condition? YES / NO <br />Are you on steroids oranti-inflammatory medications? YES / NO <br />Do you suffer from Hepatitis or other blood borne pathogen exposure or any communicable diseases? <br />YES / NO <br />Do you suffer from any medical or skin conditions: such as keloids, psoriasis or any open wounds or <br />lesions at procedural site? YES / NO <br />If yes what Kind of skin conditions? <br />Do you use Retin A, glycolic acid, vitamin C or other exfoliates YES / NO <br />Do you bruise, swell or bleed easily? YES/ <br />NO <br />Do you have an autoimmune disorder? YES / NO <br />