Emergency Contact
Are you 18 or over?
Have you had any aspirin or blood thinners in the past week?
Have you ever had any permanent makeup procedures before?
Do you have problems healing?
Have you had a chemical peel, laser, forehead / brow lift, or facial fillers ?
MM slash DD slash YYYY
Previous problems with tattoos or has your physician advised you not to have a tattoo at this time?
Do you smoke?
Have you ever had a cold sore
Are you allergic to any foods, metal, latex, antibiotics, sanitizers? If yes. please list:
Do you presently have or previously had any of the following:
History of MRSA
Diabetes
Hepatitis (A,B,C,D)
Easy bleeding
Alcoholism
Face lift
Abnormal Heart Condition
Take meds before Dental work
Brow or Lash tinting
Autoimmune Disorder
Oily Skin
Cancer year

Accutane or acne treatment
Chemotherapy/ Radiation
Tan by booth or sun
Tumors/ Growths/ Cysts
Difficulty numbing with dental work
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect. List

Any diseases or disorders not
Do you use skin care products containing Retin-A, glycolic acid or alpha hydroxyl?
FEMALE CLIENTS:
Are you pregnant or trying to become pregnant ?
Are you breastfeeding ?
Are you using oral and / or hormone based contraceptives ?
PLEASE CHECK ANY OF THE FOLLOWING THAT MIGHT APPLY TO YOU:
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