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1 Date Time (Page 2) <br /> PERMANENT MAKEUP CONSULTATION F0i-, , i <br /> (continued) <br /> Please list your skin type: <br /> O Dry 0 Combination <br /> O Oily Q Normal <br /> Are you currently pregnant or nursing? O Yes 0 No <br /> Do you have any allergies? Q Yes O No <br /> If'Yes', please list here <br /> Are you currently taking any medications including blood thinners? C?YesD No <br /> If'Yes', please list here <br /> Do you use tanning beds or spend regular time in the sun? 0 Yes 0 No <br /> Have you ever had any adverse reactions to any previous treatments? 0 Yes 0 No <br /> If'Yes', please state what kind of reaction you had <br /> Have you exfoliated or applied any products to your body in the last 24 hours? Yes 0 No <br /> If'Yes', please state what products you used <br /> Please list below any prescription or over the counter medication you are currently taking. <br /> Please list below requirements for antibiotics prior to surgery or dental procedures. <br /> Certain conditions may affect how appropriate the treatment is. Please declare all relevant <br /> history as some conditions contraindicate the treatment. <br /> ©209-601-1326 ® TANTRAINK(&YAHOO.COIM -)TANTRAINK.HPM <br />