Please circle. Flute Clarinet Saxophone - Alto/Tenor/ Baritone Bass Clarinet Oboe Bassoon Trumpet Trombone Tuba Euphonium French Horn Violin Xxxxx Cello Double Bass Percussion Acoustic Guitar Bass Guitar Piano
Please circle. Yes or No I will use this knowledge at school and everywhere I use digital technologies and the internet. Please Circle – Yes or No Students complete this section if you have opted into the Year 3-6 BYOD Program Opportunity I agree to abide by the BYOD Rules and Acceptable Use Agreement. Please Circle – Yes or No
Please circle. My child may use the Internet and email (with teacher supervision) at school according to the rules outlined. Yes No My child’s work may be published on the Internet for classroom/school purposes. Yes No Parent/Guardian Name (Please print) Signature Date **For additional information, please contact your student’s principal or FSD Technology Department** Implemented 10-12-1995
Please circle. Is this the first time you have had Microblading? Yes No Do you tint, wax or tweeze your Brows? Yes No Do you habitually rub, pull, or pick your Eyebrows for any reason? Yes No Do you have or are being treated for any illness or injury to the facial area? Yes No Do you scar easily? Yes No Do you bruise or bleed easily? Yes No Are you currently pregnant or nursing? Yes No Have you received chemotherapy or radiation in the past year? Yes No Have you ever had an allergic reaction to one of the following? Lanolin __ Latex Rubber __ Vaseline __ Medication __ Metals __ Hair Dyes __ Foods __ Lidocaine __ Paints __ Crayons __ Glycerin _ What are the main concerns relating to your eyebrows? _____________________________________________________________________________________ What would you like to improve? (Think about shape, color, density and thickness of your perfect brow.) _____________________________________________________________________________________ List any medications you have been taking in the past six months. . . _____________________________________________________________________________________ I have read and fully understand the above information provided and any risks involved with the use of topical anesthetic and I therefore consent to the use of the anesthetic for the Microblading procedure. I agree to follow pre-procedure advice closely. Clients Full Name: Clients Signature: Date: Technician’s Full Name: Technician’s Signature: Date: Please check any possible contradictions that apply to you: Have you ever had one of the following? __ Anemia __ Sensitivity to cosmetics __ Herpes __ Allergies to metals __ Alopecia __ Thyroid Diseases __ Prolonged bleeding __ Allergies to Antibiotics __ Recent high fever or severe illness __ Iron Deficiency __ Cardiac Valve Disease __ Major surgery within the last 120 days __ Retinoids used to treat acne and skin problems {Such as Accutane or Retin-A} __ Anticoagulants, Beta Allergenic blockers used to control blood pressure __ Low blood pressure __ Artificial heart valves __ Diabetes __ Hemophilia __ Fainting spells or dizziness __ High blood pressure __ Liver Disease __ Circulatory Problems __ Epilepsies __ Thyroid Disturbances __ HIV __ Hair Loss __ Hepatitis __ Cancer __ Chemical or Laser peel within 6 weeks __ Hypertrophic scars __ Keloid scars __ Healing problems __ Fat injections, Botox injections, Collagen injections How long ago? _____________________________________________________________________...
Please circle. My student may use the Internet and email (with teacher supervision) at school according to the rules outlined. Yes No Parent/Guardian Name (please print) Signature Date
