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24 21. Chemical Peel Yes No 22. Using Glycolic Acid Yes No 23. Other Tattoos Yes No 24. He Condition Yes No 25. Allergies to ANY Yes No medications or topical salves such as Bacitracin, Lanolin,Lidocane,Novacaine,Metals,Neosporine,Paba,Rubber Gloves,Latex, Lidocaine,Epinephrine,Tetracaine,Benzocaine?Are you allergic to any Antibiotics? Other 26. History of Medication Use? Yes No If yes,please list 27. Taking Medication Now? Including prescribed antibiotics prior to dental or surgical procedures? Yes No If yes,please list 28. Any other Diseases Yes No 29. Taking Blood Thinners Yes No Such as Aspirin,Coumadin,Alcohol,or Ibuprofen? 30. Do you like to get a tan? Yes No 31. Are you tanned now? Yes No 32. Do you use tanning products Yes No 33. Do you use a tanning bed Yes No 34. Any surgeries? Yes No 35• Planning cosmetic surgery? Yes No This document is Copyright protected by SofTap@ Inc. It may not be reproduced without the expressed written permission of Soffap(&Inc. Call 925 248-6301 or write to 550 N.Canyons Parkway,Livermore,CA 94551. All rights reserved. Q Copyright,2014 Sof'fap(&Inc. Seek legal advice before using this document.