Name: _________________________________________________ D.O.B. ________________ Address:_____________________________________________________ P/Code _________ Home Phone: ________________________ Business Phone: __________________________ Email: _______________________________________________________________________ May we contact you at these numbers? Y / N Mobile No. _______________________________ Referred by: __________________________________________________________________ Emergency Contact: ______________________________ Phone Number: ________________ Procedure(s) desired: Upper Eyeliner
Other: ______________________________________________________________
ALLERGIES: Check if you have ever had an allergic reaction to any of the following and describe what
happened below.
________________________ Lanolin
________________________ Bacitracin Ointment _______________________ Novocaine ________________________ PABA _______________________ Neomycin or polymyxin B ________________________ Other Allergies: __________________________________________
EYES / EYEBROWS: Check all of the following that apply.
_____________________ Contact Lenses
____________________ Eye makeup sensitivities _____________________ Thyroid abnormalities ____________________ Alopecia Universalis (total) _____________________ Glaucoma ____________________ Alopecia Areata (local) _____________________ Other hair loss, describe: _______________________________________
_____________________ Pull out lashes or eyebrows compulsively (Trichotillomania)
____________________ Eyebrow Tinting, date of last service: _______________________________
____________________ Eyelash Tinting, date of last service: _______________________________
____________________ Other eye disorders: ____________________________________________
LIPS: Check all the following that apply.
_______________________ Chapped lips
_______________________ Cold Sores / fever blisters / herpes around mouth. If yes, a prescription of
Zovirax will be required prior to any lip procedure
_______________________ Collagen injections – location __________________________________
_______________________ Fat transfer injections – location ________________________________
_______________________ Gore Tex implants – location __________________________________

SKIN: Check all of the following that apply.
_______________________ Any other tattoos – Location: __________________________________
_______________________ Age of tattoo Any problems: __________________________________
Use of sunlamp /tanning bed/suntan outdoors _______________________________
_______________________ Currently using glycolic acid or other AHA skin products YES / NO
______________________ Have you ever had a chemical peel? When?________________________
What type of peel? __________________________________________________________________
______________________ Do you have a scar you want camouflaged? Age of scar ______________
______________________ Any keloid or hypertrophic scars – location: ________________________
_______________________ Bruise or bleed easily
_______________________ Healing problems
______________________ Other active dermatological disorders. Describe: ____________________
GENERAL MEDICAL: Check all of the following that apply
_______________________ High blood pressure
_______________________ Diabetes
______________________ Current on blood thinners or anticoagulants such as Aspirin, Ibuprofen,
Coumadin, Alcohol
_______________________ Haemophilia or other clotting disorders
_______________________ Mitral valve prolapse or valve implants
_______________________ Heart palpitations
_______________________ Have you taken Accutane within the last 6 months?
_______________________ Are you pregnant or nursing?
_______________________ Ever had hepatitis – when? ___________________________________
_______________________ Autoimmune disorders
Please list any surgeries: __________________________________________________________________
If you are planning cosmetic or other surgery in the near future, please describe: ______________________
List all medications, prescription and non-prescription, that you have taken in the last two weeks:
If you are currently under a physician’s care for any condition, please describe: _______________________
Physician’s Name: ___________________________ City: ________________ Phone: _________________
This history has been reviewed by the technician and my questions have been satisfactorily

I have also received and reviewed a copy of the Pre-procedure Information sheet and After Care
Sheet, understand them and agree to follow them



TÍtulos de crÉdito na legislaÇÃo brasileira: letra de cÂmbio e nota promissÓrla

LETRA DE CÂMBIO E NOTA PROMISSÓRIA - X I - Letra de Câmbio: a) Aspectos gerais e históricos: - Muito pouco se utiliza neste país a letra de câmbio, porque com a criação da duplicata mercantil, largamente utilizada nas operações mercantis, por ser mais operacional, aquele título praticamente caiu em desuso junto aos comerciantes, mesmo porque é proibida a sua emissão, na co

119 numeriing

million per year. 50% of the 19% of Americans love pill is sold in 110 There are 62 million citizens from 15 to 24 years percentage goes up to 26% wedlock: up from 48% in for SUVs. Ditto for 32% of ( 12.7% of the total population): 16.2% in institute. 15% of Italian Poland, 15.6% in Estonia, 23% opting for black – 15.4% in Slovakia, 13.2% in wedlock

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