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

Upload1
Max File Size 15MB

Admin Only

Upload2
Max File Size 15MB
Upload3
Max File Size 15MB
Upload4
Max File Size 15MB
Upload5
Max File Size 15MB
Upload6
Max File Size 15MB

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

Upload1
Max File Size 15MB

Admin Only

Upload2
Max File Size 15MB
Upload3
Max File Size 15MB
Upload4
Max File Size 15MB
Upload5
Max File Size 15MB
Upload6
Max File Size 15MB

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

Upload1
Max File Size 15MB

Admin Only

Upload2
Max File Size 15MB
Upload3
Max File Size 15MB
Upload4
Max File Size 15MB
Upload5
Max File Size 15MB
Upload6
Max File Size 15MB

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

Upload1
Max File Size 15MB

Admin Only

Upload2
Max File Size 15MB
Upload3
Max File Size 15MB
Upload4
Max File Size 15MB
Upload5
Max File Size 15MB
Upload6
Max File Size 15MB

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

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