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Date Time (Page 1) <br /> TANTRA INK - <br /> HOUSE OIL " ERf ",NNENT MAKEUP <br /> C101 ISl 11- VI•IC I I FORNI �' ~ <br /> GENERAL INFORMATION ` <br /> Full Name DOB <br /> Address <br /> Contact Number Email <br /> What is your gender? Male L) Female (j Non-binary U Other <br /> Are you 18 years of age or over? )Yes No <br /> How did you hear about us? <br /> PERSONAL HEALTH HISTORY <br /> is this the first time receiving permanent makeup? (i Yes O No <br /> If no,when/where was your last treatment <br /> Please indicate any of the following treatments you have had in the past year: <br /> 0 Skin grafts 11 Laser resurfacing 0 Alpha hydroxyl <br /> 0 Hair removal procedures 0 Chemical Peet 0 RetinA <br /> 0 Botox 0 AHA/BHA 0 Other <br /> When was your last treatment? <br /> Do you have a history of any of the following medical conditions: <br /> 0 Alcoholism Epilepsy 0 HIV Positive <br /> 0 Alopecia 0 Eczema 0 Keloid Scarring <br /> 0 Autoimmune Disorder 0 Fainting Episodes 0 Liver Disease <br /> 0 Blisters/Herpes Simplex 0 Fever 0 MRSA <br /> 0 Bleeding Disorders 0 Forehead/Brow Lift 0 Organ Transplant <br /> 0 Cancer 0 Face Lift 0 Shingles <br /> 0 Chemotherapy/Radiation 0 Hemophilia 0 Skin Conditions <br /> 0 Diabetes 0 Other Bleeding disorders 0 Thyroid Issues <br /> 0 Dermatitis 0 Heart Condition 0 <br /> Tumours, Growths or Cysts <br /> 0 Easy Bleeding 0 Hepatitis(A,B,C,D) 0 <br /> Herpes at the Procedure <br /> O Cardiac Valve Disease High Blood Pressure <br /> Site <br /> If other,please detail <br /> When was your last treatment? <br /> Have you had any allergic reactions to any of the following? <br /> 'D/ Lidocaine(Anesthetic) �' Iron Oxide Eggs O ANTIBIOTICS <br /> TANTRAI NK'&YAHOO.COM i7TANT RAI N K.H I'^ <br />