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PERMANENT COSMETICS

How do you hear about us?

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State

City

Address:

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Age:

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Last Name

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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:

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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.

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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?

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