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SOPHIA BROWS STUDIO

10555 SE 82nd Ave, Suite 202, Happy Valley, OR 97086

Licensee: Hien Nguyen. License Number 10218518. (503) 826-4322



SEMI-PERMANENT MAKE-UP CONSENT FORM

 

This form provides information to assist in making an informed decision of whether or not to undergo a permanent cosmetics application. If you have questions, please don‘t hesitate to ask. 

Although permanent cosmetic tattooing is effective in most cases, there are biological factors specific to any individual client that are beyond our artist’s control. Every effort will be made to ensure optimal results, however no guarantee can be made that a specific look or outcome will result from the procedure. 

During the permanent cosmetics procedure pigment is deposited into the dermal layer of the skin and is a form of tattooing. 

All instruments that enter the skin or come in contact with body fluids are sealed and sterilized before use and disposed of after use. Cross contamination and bloodborne pathogen guidelines are strictly adhered to. 

Generally, the results are excellent. However, a perfect result is not a realistic expectation after an initial application. It is usual to expect a touch-up after the healing is completed. We recommend two sessions to achieve optimal desired results. However, in certain cases subsequent sessions may be needed in which case any corresponding fees will apply. 

Initially the color will appear much more vibrant and/or darker compared to the end result. Usually, within 5-7 days the color will shrink about 25% in size and the color will soften about 40-50%. The pigment will fade naturally over time and will likely need to be touched-up through the years. 

POSSIBLE RISKS, HAZARDS, OR COMPLICATIONS 

• Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others. 

• Infection: Infection is very unusual, but can occur. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. 

• Uneven Pigmentation: This can result from poor healing, infection, bleeding or many other causes. The follow up appointment can help correct any uneven appearance. 

• Allergic Reaction: If there is any concern for an allergic reaction to pigments, a patch test can be done. However, if a allergic reaction to occur, it may not show up for a long period of time, making the patch test inconclusive. 

• Asymmetry: Every effort will be made to avoid asymmetry however, anatomical facial features may not be symmetrical. Adjustments may be needed during the follow up session to correct any unevenness. 

• Excessive Swelling: Clients with sensitive skin are more prone to swelling. This should dissipate within 24 hours. 

• Acne prone: If acne is present on the forehead area, the brows may not heal correctly. If acne is a consistent issue, please consider having permanent micro pigmentation done is not in your best interest. 

• Anesthesia: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform us now. 

• MRI: Because pigments used in permanent cosmetic procedures contain inert oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your technician of any tattoos or permanent cosmetics.

 

AFTERCARE 

After care is very important for producing a beautiful and lasting result. 

• Keep the area clean by washing with freshly washed hands and a mild soap. Do not use a washcloth or sponge to remove soap. Simply splash with water. Do not use cleansing creams, acne cleansers or astringents. Use a mild, natural soap. 

• Apply the aftercare ointment with a Q-tip. Use the ointment very sparingly. We prefer a “chapstick” amount vs. a “lipgloss” amount. Wipe off excess ointment with a clean Q-tip.. Never touch the procedure area without washing your hands immediately before. 

• Do not scrub, rub or pick at the epithelial crust that forms. Allow it to flake off by itself. If it is removed before it is ready the pigment underneath it can be pulled out. 

• After the 7 days healing period, always use a sun block after the procedure area is healed to protect from sun fading. Maintaining proper skin care is suggested to help keep your brows as vibrant and fresh as possible. This means cleansing, exfoliating, and moisturizing the brow area is recommended. 

• If you have any signs and symptoms of infections we advise for you to seek medical care. These include but are not limited to: redness, swelling, tenderness of the procedure site, red streak going from procedure site towards the heart, elevated body temperature, or purulent drainage from the procedure site.

 

WHAT’S NORMAL? 

• Swelling, itching, scabbing, light bruising and dry tightness. Ice packs are a nice relief for swelling and bruising. Aftercare balm is nice for scabbing and tightness. 

• Too dark and slightly uneven appearance. After 3-7 days the darkness will fade and once swelling dissipates unevenness usually disappears. The follow-up touch up is highly recommended as any concerns can be addressed. 

• Color change or color loss. As the procedure area heals the color will lighten and sometimes seem to disappear. This is normal. The procedure area has to be completely healed before we can address any concerns. This takes at least four weeks. 

 

• Needing a touch up months or years later. A follow up touch up is recommended weeks after the initial appointment. Thereafter maintenance may be needed every 12-18 months to keep the shape symmetrical and the color refreshed. 

Failure to follow after care instructions may result in infections, pigment loss or discoloration.

 

PLEASE READ AND CHECK ALL LINES 

- I acknowledge I am age 18 or older * 

- I will tell all skin care professionals or medical personnel about my permanent makeup procedures. I understand that any skin treatments i.e. Retin A, Renova, Alpha Hydroxy and Glycolic Acids, laser hair removal, plastic surgery, or other skin altering procedures may result in adverse changes to my permanent makeup. I understand that sun, tanning beds, pools, some skin care products medications can affect my permanent makeup. 

- I understand that successful color saturation can NOT be guaranteed. I acknowledge that the proposed procedure(s) involve risks inherent in the procedure and have possibilities of complications during and/or following the procedures such as: infection, poor color retention and hyper-pigmentation. *

 

- I accept the responsibility of explaining to you my desire for specific colors, shape, and position for any procedure done today. * 

- I understand that after my service, there will be no refunds. No exceptions. * - All followup sessions must be completed no later than 12 weeks from initial session. Failure to make this appointment will incur additional costs corresponding to the amount of time that has passed since the initial session. 

- I understand that implanted pigment color can slightly change in color or in shape and fade over time due to circumstances beyond my artist control. I will need to maintain my desired results with future applications at my own expense. 

- If I have any signs and symptoms of infections I will seek medical care. These include but are not limited to: redness, swelling, tenderness of the procedure site, red streak going from procedure site towards the heart, elevated temperature, or purulent drainage from the procedure site. * 

- I grant permission to SOPHIA (ig : GO2SOPHIA), 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. 

- I acknowledge that this procedure may alter my appearance and that no representations have been made to me as to remove my permanent makeup. To my knowledge I do not have a physical, mental, medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have permanent makeup. * 

- If a dispute arises out of or relates to this contract, or the alleged breach thereof, and if the dispute is not settled through negotiation, the parties agree first to try in good faith to settle the dispute by mediation within 30 days administered under (name Rules) before resorting to arbitration, litigation, or some other dispute resolution procedure. In the event that parties are unable to agree on a mediator, a mediator shall be appointed by the named administrator. The process shall be confidential based on terms acceptable to the mediator and/or mediation service provider. * 

- I acknowledge it is not reasonably possible for my technician to determine whether I might have an ALLERGIC reaction to the pigments, anesthetic or ointment used in this process. I agree to forego a patch test and accept the risk that such reaction is possible. * 

- Notice that tattoo inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown. * 

- I agree that any touch up work needed, will be done at my own expense. * - I understand the restrictions on physical activities such as sun bathing, recreational water activities, gardening, or contact with animals, and the duration of the restrictions.

- I understand these risks and know that my participation in these services may involve risk of inflammation, irritation, swelling, redness of the eyes / skin / face, or loss of lashes or brows.

- I understand that this waiver and release of liability is intended to address all of the risks of any kind associated with my participation in any aspect of these services, including particularly, such risks created Sophia Brows. I assume all risks, known and unknown, foreseeable and unforeseeable, in any way connected with my participation of such services. I accept personal responsibility for any liability, injury, loss, or damage in any way connected with my participation in these services.

This center will not perform any procedure on anyone under 18 years of age or under the influence of alcohol or illegal drugs or who is pregnant.

 

 

 

 




First Client Name
First Name*
Last Name*
Phone*
First Client Date of Birth*
Date of Birth
First Client Information
Service Type
Date of Procedure *
Driver License Number
Do you have any bloodborne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis(A,B,C,D)*
Yes
No
Diabetes*
Yes
No
Hepatitis (A, B, C, D)*
Yes
No
Aids/HIV*
Yes
No
Hemophilia or any bleeding disorder*
Yes
No
Herpes*
Yes
No
Serious Heart Condition, cardiac valve disease*
Yes
No
Currently Pregnant or breastfeeding*
Yes
No
Have you had cancer within the last year*
Yes
No
Botox within 6 month*
Yes
No
Autoimmune Disorder*
Yes
No
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift? **
Yes
No
Eye surgery/ injury/lasik eye surgery within 1 year*
Yes
No
Accutane or prescription acne treatment within the last year*
Yes
No
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect*
Yes
No
Allergies to metals, food, latex, antibiotics.*
Yes
No
Are you using Retinol or Chemical peel skin care?*
Yes
No
History of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.*
Yes
No
If yes, what?
First Client Signature*
Second Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Second Client Information
Service Type
Date of Procedure *
Driver License Number
Do you have any bloodborne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis(A,B,C,D)*
Yes
No
Diabetes*
Yes
No
Hepatitis (A, B, C, D)*
Yes
No
Aids/HIV*
Yes
No
Hemophilia or any bleeding disorder*
Yes
No
Herpes*
Yes
No
Serious Heart Condition, cardiac valve disease*
Yes
No
Currently Pregnant or breastfeeding*
Yes
No
Have you had cancer within the last year*
Yes
No
Botox within 6 month*
Yes
No
Autoimmune Disorder*
Yes
No
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift? **
Yes
No
Eye surgery/ injury/lasik eye surgery within 1 year*
Yes
No
Accutane or prescription acne treatment within the last year*
Yes
No
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect*
Yes
No
Allergies to metals, food, latex, antibiotics.*
Yes
No
Are you using Retinol or Chemical peel skin care?*
Yes
No
History of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.*
Yes
No
If yes, what?
Third Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Third Client Information
Service Type
Date of Procedure *
Driver License Number
Do you have any bloodborne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis(A,B,C,D)*
Yes
No
Diabetes*
Yes
No
Hepatitis (A, B, C, D)*
Yes
No
Aids/HIV*
Yes
No
Hemophilia or any bleeding disorder*
Yes
No
Herpes*
Yes
No
Serious Heart Condition, cardiac valve disease*
Yes
No
Currently Pregnant or breastfeeding*
Yes
No
Have you had cancer within the last year*
Yes
No
Botox within 6 month*
Yes
No
Autoimmune Disorder*
Yes
No
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift? **
Yes
No
Eye surgery/ injury/lasik eye surgery within 1 year*
Yes
No
Accutane or prescription acne treatment within the last year*
Yes
No
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect*
Yes
No
Allergies to metals, food, latex, antibiotics.*
Yes
No
Are you using Retinol or Chemical peel skin care?*
Yes
No
History of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.*
Yes
No
If yes, what?
Fourth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Fourth Client Information
Service Type
Date of Procedure *
Driver License Number
Do you have any bloodborne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis(A,B,C,D)*
Yes
No
Diabetes*
Yes
No
Hepatitis (A, B, C, D)*
Yes
No
Aids/HIV*
Yes
No
Hemophilia or any bleeding disorder*
Yes
No
Herpes*
Yes
No
Serious Heart Condition, cardiac valve disease*
Yes
No
Currently Pregnant or breastfeeding*
Yes
No
Have you had cancer within the last year*
Yes
No
Botox within 6 month*
Yes
No
Autoimmune Disorder*
Yes
No
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift? **
Yes
No
Eye surgery/ injury/lasik eye surgery within 1 year*
Yes
No
Accutane or prescription acne treatment within the last year*
Yes
No
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect*
Yes
No
Allergies to metals, food, latex, antibiotics.*
Yes
No
Are you using Retinol or Chemical peel skin care?*
Yes
No
History of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.*
Yes
No
If yes, what?
Fifth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Fifth Client Information
Service Type
Date of Procedure *
Driver License Number
Do you have any bloodborne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis(A,B,C,D)*
Yes
No
Diabetes*
Yes
No
Hepatitis (A, B, C, D)*
Yes
No
Aids/HIV*
Yes
No
Hemophilia or any bleeding disorder*
Yes
No
Herpes*
Yes
No
Serious Heart Condition, cardiac valve disease*
Yes
No
Currently Pregnant or breastfeeding*
Yes
No
Have you had cancer within the last year*
Yes
No
Botox within 6 month*
Yes
No
Autoimmune Disorder*
Yes
No
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift? **
Yes
No
Eye surgery/ injury/lasik eye surgery within 1 year*
Yes
No
Accutane or prescription acne treatment within the last year*
Yes
No
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect*
Yes
No
Allergies to metals, food, latex, antibiotics.*
Yes
No
Are you using Retinol or Chemical peel skin care?*
Yes
No
History of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.*
Yes
No
If yes, what?
Sixth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Sixth Client Information
Service Type
Date of Procedure *
Driver License Number
Do you have any bloodborne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis(A,B,C,D)*
Yes
No
Diabetes*
Yes
No
Hepatitis (A, B, C, D)*
Yes
No
Aids/HIV*
Yes
No
Hemophilia or any bleeding disorder*
Yes
No
Herpes*
Yes
No
Serious Heart Condition, cardiac valve disease*
Yes
No
Currently Pregnant or breastfeeding*
Yes
No
Have you had cancer within the last year*
Yes
No
Botox within 6 month*
Yes
No
Autoimmune Disorder*
Yes
No
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift? **
Yes
No
Eye surgery/ injury/lasik eye surgery within 1 year*
Yes
No
Accutane or prescription acne treatment within the last year*
Yes
No
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect*
Yes
No
Allergies to metals, food, latex, antibiotics.*
Yes
No
Are you using Retinol or Chemical peel skin care?*
Yes
No
History of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.*
Yes
No
If yes, what?
Seventh Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Seventh Client Information
Service Type
Date of Procedure *
Driver License Number
Do you have any bloodborne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis(A,B,C,D)*
Yes
No
Diabetes*
Yes
No
Hepatitis (A, B, C, D)*
Yes
No
Aids/HIV*
Yes
No
Hemophilia or any bleeding disorder*
Yes
No
Herpes*
Yes
No
Serious Heart Condition, cardiac valve disease*
Yes
No
Currently Pregnant or breastfeeding*
Yes
No
Have you had cancer within the last year*
Yes
No
Botox within 6 month*
Yes
No
Autoimmune Disorder*
Yes
No
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift? **
Yes
No
Eye surgery/ injury/lasik eye surgery within 1 year*
Yes
No
Accutane or prescription acne treatment within the last year*
Yes
No
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect*
Yes
No
Allergies to metals, food, latex, antibiotics.*
Yes
No
Are you using Retinol or Chemical peel skin care?*
Yes
No
History of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.*
Yes
No
If yes, what?
Eighth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Eighth Client Information
Service Type
Date of Procedure *
Driver License Number
Do you have any bloodborne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis(A,B,C,D)*
Yes
No
Diabetes*
Yes
No
Hepatitis (A, B, C, D)*
Yes
No
Aids/HIV*
Yes
No
Hemophilia or any bleeding disorder*
Yes
No
Herpes*
Yes
No
Serious Heart Condition, cardiac valve disease*
Yes
No
Currently Pregnant or breastfeeding*
Yes
No
Have you had cancer within the last year*
Yes
No
Botox within 6 month*
Yes
No
Autoimmune Disorder*
Yes
No
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift? **
Yes
No
Eye surgery/ injury/lasik eye surgery within 1 year*
Yes
No
Accutane or prescription acne treatment within the last year*
Yes
No
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect*
Yes
No
Allergies to metals, food, latex, antibiotics.*
Yes
No
Are you using Retinol or Chemical peel skin care?*
Yes
No
History of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.*
Yes
No
If yes, what?
Ninth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Ninth Client Information
Service Type
Date of Procedure *
Driver License Number
Do you have any bloodborne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis(A,B,C,D)*
Yes
No
Diabetes*
Yes
No
Hepatitis (A, B, C, D)*
Yes
No
Aids/HIV*
Yes
No
Hemophilia or any bleeding disorder*
Yes
No
Herpes*
Yes
No
Serious Heart Condition, cardiac valve disease*
Yes
No
Currently Pregnant or breastfeeding*
Yes
No
Have you had cancer within the last year*
Yes
No
Botox within 6 month*
Yes
No
Autoimmune Disorder*
Yes
No
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift? **
Yes
No
Eye surgery/ injury/lasik eye surgery within 1 year*
Yes
No
Accutane or prescription acne treatment within the last year*
Yes
No
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect*
Yes
No
Allergies to metals, food, latex, antibiotics.*
Yes
No
Are you using Retinol or Chemical peel skin care?*
Yes
No
History of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.*
Yes
No
If yes, what?
Tenth Client Name
First Name*
Last Name*
Client Date of Birth*
Date of Birth
Tenth Client Information
Service Type
Date of Procedure *
Driver License Number
Do you have any bloodborne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis(A,B,C,D)*
Yes
No
Diabetes*
Yes
No
Hepatitis (A, B, C, D)*
Yes
No
Aids/HIV*
Yes
No
Hemophilia or any bleeding disorder*
Yes
No
Herpes*
Yes
No
Serious Heart Condition, cardiac valve disease*
Yes
No
Currently Pregnant or breastfeeding*
Yes
No
Have you had cancer within the last year*
Yes
No
Botox within 6 month*
Yes
No
Autoimmune Disorder*
Yes
No
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift? **
Yes
No
Eye surgery/ injury/lasik eye surgery within 1 year*
Yes
No
Accutane or prescription acne treatment within the last year*
Yes
No
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect*
Yes
No
Allergies to metals, food, latex, antibiotics.*
Yes
No
Are you using Retinol or Chemical peel skin care?*
Yes
No
History of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.*
Yes
No
If yes, what?
Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Service Type
Date of Procedure *
Driver License Number
Do you have any bloodborne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis(A,B,C,D)*
Yes
No
Diabetes*
Yes
No
Hepatitis (A, B, C, D)*
Yes
No
Aids/HIV*
Yes
No
Hemophilia or any bleeding disorder*
Yes
No
Herpes*
Yes
No
Serious Heart Condition, cardiac valve disease*
Yes
No
Currently Pregnant or breastfeeding*
Yes
No
Have you had cancer within the last year*
Yes
No
Botox within 6 month*
Yes
No
Autoimmune Disorder*
Yes
No
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift? **
Yes
No
Eye surgery/ injury/lasik eye surgery within 1 year*
Yes
No
Accutane or prescription acne treatment within the last year*
Yes
No
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect*
Yes
No
Allergies to metals, food, latex, antibiotics.*
Yes
No
Are you using Retinol or Chemical peel skin care?*
Yes
No
History of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.*
Yes
No
If yes, what?
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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