01
.
REGISTRATION & HISTORY
02
.
UNDERAGE CONSENT
A DAY IN PARIS, LLC.
NANO BROW REGISTRATION AND HISTORY
Date
MM
/
DD
/
YYYY
BIRTH DATE:
AGE:
Name
Address
EMAIL:
Phone
EMERGENCY CONTACT INFORMATION
CONTACT'S FIRST AND LAST NAME:
RELATIONSHIP:
PRIMARY PHONE NUMBER:
SECONDARY PHONE NUMBER:
MEDICAL HISTORY
Please select ALL allergies that apply (Presently or in the past)
LANOLIN
LATEX
VASELINE
MEDICATIONS
METALS
HAIR DYES
FOOD(S)
LIDOCAINE
PAINTS
CRAYONS
GLYCERINE
Other:
Please list ANY and ALL medications and/or supplements you are currnetly taking:
Please list any current or previous adverse reactions to services and/or products, medications, etc.:
Please select ALL that apply (Currently and in the past):
KELOID OR HYERTROPIC SCARRING
HAIR LOSS
THYROID DISEASE
HERPES
CIRCULATORY PROBLEMS
HIGH BLOOD PRESSURE
HEMOPHILIA
HIV
LUPUS
LIVER DISEASE
USE OF RETIN-A (Vitamin A)
CHEMOTHERAPY/ RADIATION
HEPATITIS A,B,C OR D
CANCER
PROLONGED BLEEDING
ANEMIA
TRICHOTILOMANIA
USE OF GLYCOLIC ACID OR ALPHA HYDROXYL ACID
USE OF ACCUTANE OR OTHER ACNE MEDICAITONS
TUMORS/GROWTHS/CYSTS
BLOOD THINNERS (ASPIRIN, IBUPROFEN, ETC.)
PREGNANT OR BREAST FEEDING
LOW BLOOD PRESSURE
ARTIFICIAL HEART VALVES
DIABETES
HYPERHIDROSIS
PREVIOUS TREATMENTS AND PROCEDURES
Please select ALL that apply:
BOTOX
CHEMICAL PEEL
LASER HAIR REMOVAL
COSMETIC FACE SURGERIES
AHA PREPARATIONS
FILLERS
MICROBLADING, MICROSHADING, OR ANY OTHER METHOD OF BROW TATTOOING
If you checked yes for ANY of the above services, please provide WHEN those services were completed:
SKIN TYPE (CHECK ALL THAT APPLY):
NORMAL
OILY
DRY
COMBINATION
SEVERE SENSITIVITY
MILD SENSITIVTY
FITNESS LEVEL
I DO NOT WORK OUT REGULARLY
LIGHT (MINIMAL SWEATING)
MODERATE (MODERATE SWEATING)
HARD (HEAVY SWEATING)
SWIMMING DAILY OR WEEKLY
ACKNOWLEDGEMENT
I AGREE THAT THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE, AND THAT I HAVE DISLCOSED ANY AND ALL CONDITIONS AND/OR HISTORY THAT MAY BE AT RISK OFR REACTIONS TO ANY SERVICES RECEIVED.
FIRST NAME: LAST NAME:
Signature
Clear
Date
MM
/
DD
/
YYYY
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01
.
REGISTRATION & HISTORY
02
.
UNDERAGE CONSENT
A DAY IN PARIS, LLC.
NANO BROW REGISTRATION AND HISTORY
I am the natural parent or legal guardian of:
The Minor Child's date of birth is:
MM
/
DD
/
YYYY
I have the legal authority to consent for this child's tattoo. (PLEASE INTIAL)
I CONSENT FOR MY CHILD TO GET THE FOLLOWING TATTOO (describe the desired tattoo and its location):
Print Name:
Date
MM
/
DD
/
YYYY
Signature
Clear
SUBMIT FORM
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