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Ink Disclosure: <br /> I acknowledge that pigments used in PMU are not FDA-approved, and potential long-term <br /> effects are unknown. <br /> Client Acknowledgment <br /> ❑ I have read and understand the information provided above. <br /> ❑ I have had the opportunity to ask questions regarding the procedure. <br /> ❑ I consent to the performance of the permanent makeup procedure as described. <br /> Client Signature: Date: <br /> Technician Signature: Date: <br /> Medical Questionnaire (H&SC §119303(b)) <br /> Question Yes No <br /> Are you pregnant or breastfeeding? ❑ ❑ <br /> Do you have a herpes infection near the procedure area? ❑ ❑ <br /> Do you have diabetes? ❑ ❑ <br /> Are you allergic to latex? ❑ ❑ <br /> Are you allergic to antibiotics? ❑ ❑ <br /> Do you have hemophilia or bleeding disorders? ❑ ❑ <br /> Do you have a heart condition or valve disease? ❑ ❑ <br /> Are you currently taking any medications? ❑ ❑ <br /> Do you require antibiotics before dental or surgical procedures? ❑ ❑ <br /> Do you have any risk factors for blood-borne pathogens (Hepatitis, HIV, etc.)? ❑ ❑ <br /> Post-Procedure Care Instructions (H&SC §119303(a)(5)) <br /> You will receive written aftercare instructions including: <br /> • Proper care for your PMU site <br /> • Restrictions on swimming, exercise, and sun exposure <br /> • Signs and symptoms of infection <br /> • When to seek medical attention <br />