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Medical Questionnaire

Please list any other allergies you have.

Please list any medications you are currently on.

Please list any illnesses or medical conditions you are currently being treated for by a medical professional, including current treatment for cancer.

Consent

Please submit.

If an unforeseen condition arises in the course of the procedure, I authorize Khrista to use her professional judgement to decide what she feels is necessary under the given circumstances. I understand removal solutions have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown. I understand and accept that results vary and I understand that no time frame is guaranteed to me. I understand and accept that each procedure is a process and may require multiple applications of removal solution to achieve desired results and that 100% success cannot be guaranteed during the first procedure. I may have to return for a repeated procedure. I understand the nature of the procedure and adverse effects that may occur as a result of applied pigments. Adverse effects include: redness, swelling, puffiness, corneal abrasions, dark patches, allergic reactions, tenderness, infection, or migration. In addition, I understand that there is a possibility of hyper pigmentation or scarring resulting from a procedure, especially in individuals prone to hyper pigmentation from a scar or other injury. I have been informed that the highest standards of hygiene are met and that sterile disposable needles and pigment containers are used for each individual client, procedure, and visit. I agree to read the aftercare instructions that been provided and explained to me by Khrista. I understand that achieving the results I desire will, in some measure, be determined by my compliance to these instructions. I have been given the opportunity to ask questions about the procedure, equipment, past experience, and the methods to be used, as well as, the risks and hazards involved. I believe that I have sufficient information to give this informed consent. I understand the taking of before and after photographs of procedures maybe required and that some photographs may be taken during the procedure. I also understand that exceptional photographs or results may be used in advertising or promotional materials and give permission for such usage. - I have read and fully understand the above information. I have given an accurate account of the questions. If I have any concerns, I will address these with Khrista. I give permission to Khrista to perform the service we have discussed. I agree to adhere to the aftercare instructions as recommended by Khrista. I understand that Khrista will take every precaution to minimize or eliminate negative reactions as much as possible. Despite all precautionary measures Khrista takes, injury is possible. I will hold Khrista harmless from any liability, responsibility, damages or issues that may result from this service.

CRC NON-LASER REMOVAL

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