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Are you under the influence of drugs or alcohol? yes no Have you ingested anticoagulants(such as heparin or warfarin),antiptatelet drugs,or nonsteroidal anti- inflammatory drugs (NSAIDS) (such as aspirin, ibuprofen,etc.) in the last 24 hours? yes no Have you ingested any medication that can inhibit the ability to heal a skin wound? yes no Do you have any allergies or adverse reactions to dyes, pigments, latex, iodine,or other such products or antibiotics? yes no Do you have hemophilia,epilepsy,a history of seizure,fainting, narcolepsy, or other conditions that could interfere with the body art procedure? yes no Do you have a history of skin diseases that might inhibit the heating of the body art procedure/permanent makeup procedure? yes no Do you have any communicable diseases (i.e.,hepatitis A, hepatitis B, HIV,or any other disease that could be transmitted to another person during the procedure)? yes no Do you have diabetes, high blood pressure, heart condition, heart disease,or any other conditions that could interfere with the body art procedure? yes https://form.jotform.com/231451878214154 5/12/25, 2:10 AM Page 5 of 9