430 18th St. Suite 7 Bakersfield, CA 93301
(661)304-6383
Follow-Up Health and Medication Update Form
Name
*
First Name
Last Name
Have there been any changes in your health history? Please answer 'Yes' or 'No.'
*
Please Select
Yes
No
If 'Yes,' kindly provide details below.
Have you started taking any new medications or supplements? Please answer 'Yes' or 'No.'
*
Please Select
Yes
No
If 'Yes,' kindly provide details below.
I understand that all sales ar final and the the services rendered are non-refundable. I waive my right to request a refund or chargeback through my bank.
*
I understand and agree
I, the undersigned, hereby release and hold harmless Revive Medical Tattooing and its representatives from any and all claims, damages, or liabilities arising from my decision to undergo permanent makeup, scar and stretch mark camouflage, inkless treatments, 3D areola tattoos, or any other treatments provided. I fully understand the nature of these procedures, including the potential risks, side effects, and outcomes. I confirm that I have disclosed all relevant medical history and received aftercare instructions. By signing below, I acknowledge that I am choosing to proceed voluntarily and accept all associated responsibilities and risks.
*
Date Signed
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Month
-
Day
Year
Date
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