Client Submitted Consent Forms
What kind of procedure?
How do you hear about us?
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.
Uploaded Image 5
Uploaded Image 1
Uploaded Image 2
Uploaded Image 3
Uploaded Image 4
Uploaded Image 6
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?