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Abnormal Heart Condition Eye surgery or injury <br /> Cold Sores Blepharoplasty (eyelid surgery) <br /> Herpes Simplex or infection at the procedure site Visual Disturbances <br /> Hemophilia or other bleeding disorders Cancer <br /> High or Low Blood Pressure Tumors/Growths/Cysts <br /> Prolonged Bleeding Chemotherapy/ Radiation <br /> Circulatory Problems Are you pregnant or nursing ? <br /> Epilepsy/seizures of any kind ? Hepatitis <br /> Diabetes Do you wear contact lenses ? <br /> Fainting spells/dizziness Keloid condition <br /> Cataracts Cardiac Valve Disease <br /> Glaucoma Eye Drops or Ocular Medications <br /> " Dry Eye " Hyper- pigmentation <br /> Corneal Abrasions Currently taking aspirin /ibuprofen <br /> Botox or injectables ? If so , when ? <br /> Do you take Antidepressants or mood altering mediations ? <br /> Do you have any problems with healing ? <br /> Have you had caffeine products in the last 24 hours ? <br /> Are you taking any medication , including immunosuppressive , such as anti4lammatory or <br /> steroids ? <br /> Are you allergic to topical antibiotic preparation ? ( ie . Polysporin , Bacitracin , Neosporin , or <br /> Caine family of drugs or Petroleum based products - vaseline ) ? <br /> Is there any history of skin diseases or remarkable skin sensitivities ? <br /> Are you presently taking Vitamins A , E or fish oil in any form ? <br /> Are you required to take antibiotics during dental or invasive medical procedures ? <br /> Do you have alopecia ? <br /> Any tendency to bleed excessively from minor cuts ? <br /> Do you have any Autoimmmune Disorders ? <br /> Do you have HIV or other risk factors for blood borne pathogens ? <br /> When was your last eye exam ? <br /> Examining Physician : <br /> Signature Date <br /> POST PROCEDURE INSTRUCTIONS <br /> FOR ALL PROCEDURES <br /> ( Eyebrows , Eyeliners , Lip Liner/ Full Lips , Areola , and Scar Camouflage ) <br /> Immediately Following Cosmetic Tattoo Procedure : <br /> 5 <br />