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PRACTITIONER MAKES NO ATTEMPT TO, OR CLAIM TO, PRACTICE MEDICINE. SOME INDIVIDUAL 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 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. DO YOU, OR HAVE YOU HAD, ANY OF THE FOLLOWING: ❑ TUB ERCULOSIS F-1 HEMOPHILIA OR OTHER BLEEDING DISORDERS ❑TRICHOTILLOMANIA ❑ALLERGIES TO MAKEUP ❑ MENOPAUSE/RUN HOT/FREQUENT HOT FLASHES ❑ HEPATITIS/HIV M RSA/STAPH ❑ KIDNEY DISEASE/TRANSPLANT I-] ON BLOOD THINNERS ❑LIVER DISEASE/CIRRHOSIS ❑ ECZEMA/DERMATITIS ❑ KELOIDS ❑DIABETES ❑ACCUTANE TREATMENT ❑STROKE/PARALYSIS 1:1 THYROID ISSUES/MEDS ❑ HEART CONDITIONS/PACE MAKER/DEFIBRILLATOR ❑SHORTNESS OF BREATH ❑ HYPER -PIGMENTATION ❑ALOPECIA ❑ HYPO -PIGMENTATION ❑AUTOIMMUNE DISORDERS ❑ REFRACTIVE EYE SURGERY ❑ EPILEPSY/SEIZURES ❑EYELID SURGERY ❑SMOKER ❑ LASIK SURGERY ❑CATARACT SURGERY ❑TEAR DUCT PLUS ❑ GLAUCOMA ❑CANCER (LIST BELOW) ❑ COPD ❑TAKE VITAMINS ❑ ROSACEA ❑ HAVE A FOREHEAD/BROW LIFT (YR. ) ❑ HEAD INJURY/TRAUMA (HIT THE HEAD, ACCIDENTS) ❑ ORGAN TRANSPLANT ❑ USE LASH/BROW SERUM ❑VITILIGO ❑ HERPES AT THE PROCEDURE SITE ❑ COLD SORES ❑ OCULAR HERPES ❑SHINGLES F-] CARDIAC VALVE DISEASE ❑OILY, T -ZONE, COMBINATION Ll OTHER RISK FACTORS FOR ❑SCARS IN AREA TO BE DONE? ❑ BOTOX (DATE OF LAST TX) BLOOD BORN PATHOGENS OTHER MEDICAL CONDITIONS/SURGERIES PLEASE EXPLAIN ANY CHECKED QUESTION, LIST ANY OTHER MEDICAL CONDTIONS OR ALLERGIES, AND LIST ALL OF YOU MEDICATIONS CLIENT'S SIGNATURE: DATE: ADORN BEAUTY INK