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Permanent Makeup & Tattoo Removal,
Carbon Facials Consent Form

Medical History
Do you have any allergies?
Are you currently (or possibly may be) pregnant or breastfeeding?
Do you have any other medical condition?

Consent

While allergies to treatment are unusual, it is always possible to have a reaction in regards to any new treatments we undertake. Please review and tick the boxes as you go along to make it clear that you are aware and have take all of this into consideration.

Please tick the boxes to show you agree: Required
Please select one:
Health and Lifestyle

Contra Indications/ Conditions requiring special considerations

Do you have any of the following:

Medication

To ensure that you have no adverse reaction to treatments,it is important for us to know if you are taking any medication. Some medications and alternative /herbal remedies can photo-sensitize the skin and you may need to ask for your doctor's consent before we can proceed with treatment.

Are you taking medication or Recreational drugs-please list?
Are you currently,or have you used, Roaccutane, isotretinoins or Retin A in the last 6 months?
Have you taken St John's Wort in the past three months?
Are you taking any homeopathic Chinese or Herbal remedies that may photo-sensitize your skin?
Have you taken anti-histamines.antibiotics,cold remedies or pain-killers in the past 2 days?
Have you taken any anti-coagulants,Warfarin/Heparin or gold therapy in the past 3 months?
General Information
Have you ever had a chemical peel (e.g., AHA's) or Microdermabrasion
Do you use sun beds, spray tanning products or tinted moisturizers?
Are you currently pregnant or trying to conceive?
Have you had injectable fillers (e.g. Collagen, Restylane or Botox) in last 6 months?
Do you have mole, birthmarks, tattoos or permanent make-up in treatment area?
Do you suffer with any acute or chronic skin conditions in the treatment area?
Do you take any form of exercise?
Do you smoke?
Do you drink alcohol?
Skin Type
Skin Color Required
Have you had any sun exposure or used a sunbed in the last 4 weeks?
Do you use self-tan products?
Have you used deodorant, sun block or essential oils on the area to be treated within the last 24 hours
Proposed Area For Treatment
Treatment Type Required
Areas to be Treated Required
Treatment Validation & Expectations

By Signing below, I verify that I have read and understand the above statements and agree to them.

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