Consent For Permanent Cosmetic Removal Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * ALLERGIES * Check All That Apply. Vasoline or A&D Soap Cosmetics Novocain Allergic To Antibiotics Alcohol Metals Other Allergies Other Drugs Check All That Apply To The Brow Or Eyes Glaucoma Eye Make-up Sensitivities Dry Eyes Tyroid Abnormalities Blurred Vision Contact Lenses Check All the Apply To The Lips Scars Cold Sores Collagen Injections Implants Check All That Apply To You Keloid or Hypertrophic Scars Heart Condition HIV MRSA/Staph Infection Eczema/ Psoriasis Bruise or Bleed Easily Hyperpigmentation Other Clotting Disorders Epilepsy Pregnant/Nursing Diabetes Healing Problems Other Dermatological Disorder Hepatitis Herpes Blood Thinners Asthma Chemical Peel If Chemical Peel, When? OTHER Please list all medications that you have taken within the last two weeks: If you are currently under a physicians care for any condition please describe: This History has been reviewed and all of my questions have been answered. Date MM DD YYYY I have had post procedure Instructions explained to me. * Yes No Understand I must be 18 or older to have procedure. ID checked. * Typed Signature * Thank you! I Do Not Approve Signature
