Permanent Make-up Medical History Form Today’s Date: MM slash DD slash YYYY Birth Date: MM slash DD slash YYYY Name: Home Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Work Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone:Work Phone:Employer: Occupation: Are you now or have you been under the care of a physician within the last two years? (Check One) Yes No If yes, please provide Physician’s Name, address and phone number. Person to contact in case of an emergency:Name: Phone No.List all medication you are currently taking, including Retin-A, Glycolic Acid and Acutane: List any drug, makeup, skin or food allergies (i.e., soaps or cleansing creams): Have you recently undergone a skin peel? What products do you use for skin care? Do you have or have you had any of the following conditions: Abnormal Heart Condition Cold Sores Herpes Simplex Hemophilia High or Low Blood Pressure Prolonged Bleeding Circulatory Problems Epilepsy Diabetes Fainting Spells/Dizziness Cataracts Glaucoma Dry Eye Corneal Abrasion Eye Surgery or Injury Blepharoplasty (eyelid surgery) Visual Disturbances Cancer Tumor/Growths/Cysts Chemotherapy/Radiation Are you pregnant? Hepatitis Do you wear contact lenses? Do you use tobacco products? Are you using any eye drops or other ocular medication? Have you ever experienced hyper-pigmentation from an injury? Are you currently taking aspirin or ibuprofen? None of the Above When was your last eye exam? MM slash DD slash YYYY Examining Physician: SignatureDate MM slash DD slash YYYY I understand that no warranty or guarantees have been made to me as to the results I understand that there is a possibility of hyper-pigmentation resulting from this procedure, especially in individuals prone to hyper-pigmentation from a scar or other injury. I have been told that there may be risks and hazards related to the performance of the procedure planned for me. I have been told that this procedure will involve pain and discomfort. I have been told that the markings are permanent and there is a risk of infection following the procedure. I have been told that a follow up procedure may be required and that the color of pigmentation may fade. I have been told that there is a chance that I may experience a corneal abrasion from the eyeliner procedure. I have been told that there is a chance of allergic reaction to pigment and that my body may reject the pigment. I have been given an opportunity to ask questions about the procedures to be used and the risks and hazards involved and I believe that I have sufficient information to give my informed consent. I have agreed that should I have a complaint of any kind whatsoever, I shall immediately notify Mandy Dhillon and I further agree that any controversy or claim arising out of or relating to this consent and/or any signed contract between myself and Mandy Dhillon or the breach thereof, shall be settled by arbitration in the state of Virginia in accordance with the Rules of the American Arbitration Association and judgement of the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify Mandy Dhillon and the Virginia Department of Health. I have received a copy of the Post Procedure Instructions. It has been fully explained to me and I have read it or it has been read to me. I understand its contents. PRE-TREATMENT ADVICE AND PROCEDURES Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear “crusty” for up to one week. Please wear your normal make-up to the procedure. If you are having lips or brows done, please bring your favorite pencils. If unwanted hair is normally removed in the area to be treated, i.e.; tweezing or waxing, the hair removal should be done at least 24 hours prior to your procedure. Electrolysis should not be done within five days of the procedure. Do not resume any method of hair removal for a week after the procedure. If eyelashes or eyebrows are normally dyed, do not have that procedure done within 48 hours of this procedure. Wait one week after the eyebrow or eyeliner procedure before dying lashes or brows. If you wear contact lenses and are having the eyeliner done, do not wear your lenses to your appointment and do not replace them until the day after the procedure. If you are having the eyeliner procedure done, as a safety precaution, in case of watering or swelling, we recommend that you have someone available, or accompany you, who could drive you home if you so decide, so if it is necessary. If you are having lip liner done and you have had previous problems with cold sores, fever blisters, or mouth ulcers, the procedure is likely to reactivate the problem. Your Intradermal Technician can make recommendations to help prevent or minimize the outbreak. We recommend allergy testing of the red pigment (lip liner or skin tone pigments) one week before the planned procedure. Do not use aspirin or ibuprofen for 7 days prior to the procedure. We look forward to working with you. If you have any questions, please call or make notes so we can discuss them with you when you arrive for your appointment.