TN
Beauty
Client Submitted Consent Forms
PERMANENT COSMETICS
How do you hear about us?
What kind of procedure?
Zip Code
State
City
Address:
Email:
Age:
Phone Number
Last Name
First Name
Date
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift?
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect
Allergies to metals, food, latex, antibiotics.
Currently on any blood-thinning prescription drugs
If yes, what and when?
Special Requests, Concerns, Note to Technician:
I grant permission to TN-Beauty, Thunyatorn LLC, Thai Serenity Spa to take and use: photographs and/or digital images of me for use in news releases, educational materials and/or social media platforms including but not limited to Instagram, Facebook, and Pinterest. If no photo please inform your your artist.
Photo Permission:
Uploaded Image 5
Uploaded Image 1
Uploaded Image 2
Uploaded Image 3
Uploaded Image 4
Uploaded Image 6
Admin Only
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Your content has been submitted
Eye surgery/ injury/lasik eye surgery within 1 year
Diabetes, Pregnancy, Nursing, Lupus, Hepatitis (A,B,C,D), AIDS, Active Skin Disorders: Cold Sores, Shingles, Impetigo, Psoriasis, Pink Eye, Sun Burn, Severe Acne, Herpes, Active Vitiligo, Severe Rosacea, Blood Disorders: Sickle Cell, Hemophilia, Keloid Formation, Mental Disorder, Accutane (must be 0_ for 6 months), Steroids (must be 0_ for 6 months), Retinol/Retin-A (stop using 7 days prior) Do the medical list above apply to you in any way?
Client Information
Medical Record
How do you hear about us?
What kind of procedure?
Zip Code
State
City
Address:
Email:
Age:
Phone Number
Last Name
First Name
Date
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift?
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect
Allergies to metals, food, latex, antibiotics.
Currently on any blood-thinning prescription drugs
If yes, what and when?
Special Requests, Concerns, Note to Technician:
I grant permission to TN-Beauty, Thunyatorn LLC, Thai Serenity Spa to take and use: photographs and/or digital images of me for use in news releases, educational materials and/or social media platforms including but not limited to Instagram, Facebook, and Pinterest. If no photo please inform your your artist.
Photo Permission:
Uploaded Image 5
Uploaded Image 1
Uploaded Image 2
Uploaded Image 3
Uploaded Image 4
Uploaded Image 6
Admin Only
An error occurred. Try again later
Your content has been submitted
Eye surgery/ injury/lasik eye surgery within 1 year
Diabetes, Pregnancy, Nursing, Lupus, Hepatitis (A,B,C,D), AIDS, Active Skin Disorders: Cold Sores, Shingles, Impetigo, Psoriasis, Pink Eye, Sun Burn, Severe Acne, Herpes, Active Vitiligo, Severe Rosacea, Blood Disorders: Sickle Cell, Hemophilia, Keloid Formation, Mental Disorder, Accutane (must be 0_ for 6 months), Steroids (must be 0_ for 6 months), Retinol/Retin-A (stop using 7 days prior) Do the medical list above apply to you in any way?
Client Information
Medical Record
How do you hear about us?
What kind of procedure?
Zip Code
State
City
Address:
Email:
Age:
Phone Number
Last Name
First Name
Date
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift?
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect
Allergies to metals, food, latex, antibiotics.
Currently on any blood-thinning prescription drugs
If yes, what and when?
Special Requests, Concerns, Note to Technician:
I grant permission to TN-Beauty, Thunyatorn LLC, Thai Serenity Spa to take and use: photographs and/or digital images of me for use in news releases, educational materials and/or social media platforms including but not limited to Instagram, Facebook, and Pinterest. If no photo please inform your your artist.
Photo Permission:
Uploaded Image 5
Uploaded Image 1
Uploaded Image 2
Uploaded Image 3
Uploaded Image 4
Uploaded Image 6
Admin Only
An error occurred. Try again later
Your content has been submitted
Eye surgery/ injury/lasik eye surgery within 1 year
Diabetes, Pregnancy, Nursing, Lupus, Hepatitis (A,B,C,D), AIDS, Active Skin Disorders: Cold Sores, Shingles, Impetigo, Psoriasis, Pink Eye, Sun Burn, Severe Acne, Herpes, Active Vitiligo, Severe Rosacea, Blood Disorders: Sickle Cell, Hemophilia, Keloid Formation, Mental Disorder, Accutane (must be 0_ for 6 months), Steroids (must be 0_ for 6 months), Retinol/Retin-A (stop using 7 days prior) Do the medical list above apply to you in any way?
Client Information
Medical Record
How do you hear about us?
What kind of procedure?
Zip Code
State
City
Address:
Email:
Age:
Phone Number
Last Name
First Name
Date
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift?
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect
Allergies to metals, food, latex, antibiotics.
Currently on any blood-thinning prescription drugs
If yes, what and when?
Special Requests, Concerns, Note to Technician:
I grant permission to TN-Beauty, Thunyatorn LLC, Thai Serenity Spa to take and use: photographs and/or digital images of me for use in news releases, educational materials and/or social media platforms including but not limited to Instagram, Facebook, and Pinterest. If no photo please inform your your artist.
Photo Permission:
Uploaded Image 5
Uploaded Image 1
Uploaded Image 2
Uploaded Image 3
Uploaded Image 4
Uploaded Image 6
Admin Only
An error occurred. Try again later
Your content has been submitted
Eye surgery/ injury/lasik eye surgery within 1 year
Diabetes, Pregnancy, Nursing, Lupus, Hepatitis (A,B,C,D), AIDS, Active Skin Disorders: Cold Sores, Shingles, Impetigo, Psoriasis, Pink Eye, Sun Burn, Severe Acne, Herpes, Active Vitiligo, Severe Rosacea, Blood Disorders: Sickle Cell, Hemophilia, Keloid Formation, Mental Disorder, Accutane (must be 0_ for 6 months), Steroids (must be 0_ for 6 months), Retinol/Retin-A (stop using 7 days prior) Do the medical list above apply to you in any way?
Client Information
Medical Record