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Haven Medi-Spa Health Waiver 

Please take the time to fill out and submit this online waiver prior to your appointment to confirm that you are a candidate for your desired treatment and to ensure that we are treating you as safely as possible throughout

Permanent Makeup Intake Form*

Please fill out the following form to ensure that you are being treated accordingly

List B

Medical History

Do you have or have you had any of the following conditions? If yes, please select them:

List A
List B
List B
Have you ever had an allergic reaction to latex?
Have you ever had an allergic reaction to antibiotics?
Any known allergies?
Have you taken any of the following in the last 2 days: Aspirin, Ibuprofen, Coumadin, Alcohol?
Do you wear contact lenses?
Do you typically bruise easily?
Do you often have eye irritation, itching or watery eyes?
Do you have any tattoos?
Have you had any recent surgeries?
Do you often wear makeup on your brows, eyes, lips?
Do you have any concerns regarding the treatment?

*Question specific for lip services

Have you ever had a cold sore?

Please note that if you have ever experienced a cold sore in the past, you will be required to take Valtrex prior to your lip service (prescription from your health care provider).

Client History

Have you had any permanent or semi-permanent makeup services done before?

Pleaes check off any of the following surgeries you've had.

List B
Have you had any facial or dermatology services in the last 30 days?
Have you recently done a chemical peel?
Are you currently wearing lash extensions?
Do you have a tanned/sunburnt skin?
Have you used Latisse or any eyelash/eyebrow growth conditioner within the last 2 months?
Have you received Accutane (acne medication) within the last year?
Have you received Botox, Lip fillers, Restylane, Juvederm or Collagen in the last 6 months?
Have you used Retin-A, Renova, AHA, BHA, Retinoid or Retinol products in the last 3 months?

Please note that all information provided above will be held in strict confidentiality. All information will be used by service provider to ensure quality and safety of clients.

By signing below, you agree to the following:

I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition/s that would make the requested
treatment unsuitable. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health.

Thanks for submitting!

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