Form


Eyeliner Eyebrows
Lipline Full Lip Color
Skin Repigmentation
Beauty Mark Tattoo Removal
Other, please explain


Yes
No
If yes, contact your physician for a prescription of ZOVIRAX or some other anti-viral medication.

I have read above information regarding an anti-viral and understand its use is mandatory if I desire lipline or full lip color procedures.

Who reffered you

Are you currently under the care of a physician?
Yes
No

If so, why?
Physician's name:

Do you take antibioties when going to the dentist?
Yes
No
If yes, why?

Do you suffer from:
Allergies Hemophilia
Moles of freckles at site of tattoo
Diabetes Hepatitis
Skin problem Heart problems
Scarring (Keloids)

Are you presently taking any medication which thins the blood?
Yes No

Are you taking other medication anti-depression or mood altering drugs?
Yes No

If yes, explain:

Are you pregnant or nursing?
Yes
No

Do you wear contact lense?
Yes
No

If yes, bring glasses to your eyeliner appointment as you cannot put in contact lenses directly after a procedure.

I'm aware that I'll be photographed before and after the procedure. I'm aware
I'm informed how to perform self-care. I'm informed
The above is complete and accurate as to my medical history Yes