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COJPIDENTIAL MEDICAL PROOLE 4 -N&me: Date: Address: City: State: Zip: Doe) Cell Phone: Referred By: To avoid unforeseen complications, please answer the following questions: Yes No Are you under the age of 18? Legal guardian initials: Yes No Have you had any aspirin or blood thinning products within the last 7 days? Yes No Have you had any mood altering drugs within the last 6 hours? 1 Yes No Do you have any history of cold sores, herpes, or fever blisters? Yes No Are you sensitive to latex? Yes No Have you had a chemical or laser peel? If so, when? Yes No Do you have problems with healing? Yes No Have you had any previous problems with tattoos, or as has your physician advised you d ised not to have a tattoo at this time? Yes No Are you currently undergoing radiation or chemotherapy? Yes No Are you currently using Retin-A or Alpha Hydroxy skin care products? Yes No Do you wear contact lenses? (If yes, I understand they must be removed before a !v eyeliner procedure and should not be replaced until the next day) Yes No Are you allergic to any metals? Yes No Have you ever had any permanent make-up procedures before? Yes No Are you taking any anti-inflammatory medication or steroids? Yes No Are you suffering from withdrawal from caffeine products? I Yes No Are you allergic to topical antibiotic preparations or desensitizers? IT k_.E. polysporin, bacitracin, Neosporin or"Caine"family of drugs or petroleum) Yes No Do you have a history of any skin diseases or remarkable skin sensitivities" Yes No Are you currently taking Vitamin A and/or E in any form? Yes No Are you pregnant or nursing? Yes No Are you required to take antibiotics during dental or invasive medical procedures? Please explain any checked question i Please circle any of the following that may pertain to you: and list any other medical conditions and all mg--gications currently being Heart Conditions Hepatitis/Jaundice HIV Allergies to makeup Kidney disease takcn; Accutane treatment Tendency to develop fever a Dry eyes Blisters on lips 5 Shortness of breath Hyper-pigmentation (darkening of skin) Keloid or hypert-ophy scarsExcessive blending from minor injuries Keloid formation Chest pains Refractive eye surgery Glaucoma Alopecia Epilepsy/seizures Diabetes Stroke I Autoimmune disorders Ocular herpes 54 Trichotillomania Cancer(any type) Doctoes Name. PLC Phone- piractt.(M, -10� ract, 'r to Petr4nt ar makeNW- tip C 4b—ft�. f-- S ale always a Pp.$ the __"41, For fn I