Smoky Eyeliner Confidential Medical Profile
Date of Birth:
Are you under the age of 18?
Are you pregnant or nursing?
Have you had any blood thinning agents in the last 7 days?
Have you had any mood altering agents within the last 24 hours?
Do you have a history of herpes, cold sores, or fever blisters?
Do you have a history of skin disorders or remarkable skin sensitivities?
Do you have problems with healing?
Have you had any permanent makeup procedures before?
Have you had any previous problems with tattoos/permanent makeup?
Are you currently undergoing chemotherapy or radiation?
Are you currently using Retin A or alpha-hydroxy skin care products?
Have you had a chemical laser peel in the last 30 days?
Do you wear contact lenses or false eyelashes?
Please check that applies:
Please list all medications you are currently taking:
Practitioner makes no attempt, or claim, to practice medicine. Some individuals will have complications related to permanent makeup application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. By signing this consent you are acknowledging that you are in good health and there are no apparent reasons to restrict you from receiving a tattoo.
Leave this empty:
Your legal name
Signed by Katelyn McCloy
Signed On: October 1, 2018
If you have questions about the contents of this document, you can email the document owner.
Document Name: Smoky Eyeliner Confidential Medical Profile
Agree & Sign