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Microblading & Tattooing by Mimi Chaves Diva’s Salon & Spa – 801 South Ham Lane, Lodi, CA 95242 Cell: (805) 260-2329, Email: mjcmicroblading@gmail.com Page 1 of 5 MEDICAL HISTORY FORM Important Questions to better serve you: 1. Are you over 18 years old? YES or NO Please provide ID to make copy 2. You are aware that the pigment (inks) are not FDA approved, and that the health consequences are unknown? YES or NO 3. Are you pregnant or could you be pregnant? YES or NO 4. Do you have a history of herpes infection around the working area? YES or NO 5. Do you have diabetes? YES or NO 6. Do you have allergies to any antibiotics or medication? YES or NO 7. Are you allergic to latex? YES or NO 8. Do you have any history of cardiac arrest or valve disease? YES or NO 9. What are your current medications? Are you required to have any antibiotics before any dental or surgery procedure? YES or NO 10. Are you taking over the counter medications? YES or NO 11. Are you taking blood thinners? YES or NO 12. Do you have any factors of other blood borne pathogens? YES or NO 13. Do you have any present illness or history of an illness? YES or NO 14. Are you presently using an exfoliating like AHA or Retin-A or collagen? YES or NO 15. Do you have any blood disease? For example, Hepatitis, HIV, Aids, etc YES or NO 16. Do you have any healing problems? YES or NO 17. Have you ever had a cold sore? YES or NO 18. Do you have a keloid condition? YES or NO 19. Do you have cancer or are you in any kind of chemo treatment? YES or NO 20. Do you have a history of hemophilia or others bleeding disorders? YES or NO 21. Do you have other risk factors for blood borne pathogens? YES or NO Please provide clarification if you have answered "YES” to any of the questions above: As evidenced by signature and show of ID, I understand and agree to the above conditions for which the procedure will preformed. Printed Name Phone Number Signature Date Address