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To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions: <br />Do you have previous Permanent Make Up? If yes, when? <br />_ Are you over the age of 18? <br />_ Have you had Aspirin or any blood thinning medications/supplements within the last 7 days? _ Do you take Antidepressants or mood - <br />altering medication? <br />_ Have you had a chemical or laser peel? If so, when? <br />Do you have any problems with healing? <br />_Are you currently undergoing radiation or chemotherapy? <br />_ Are you currently using Retin-A or Alpha Hydroxyl skin care products? <br />_Are you taking medication, Including immunosuppressive, such as anti-inflammatory or steroids? <br />Are you allergic to topical antibiotics? <br />e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or petroleum-based products (Vaseline)? <br />_ Is there any history of skin diseases or remarkable skin sensitivities? <br />_ Are you pregnant or nursing? <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 any heart conditions? <br />_ Have you had Botox or injectables. If yes, when? <br />_ Do you have Alopecia? <br />_ Are you currently on Accutane Treatment? <br />_ Do you have Keloid or Hypertrophic Scars? <br />_ Do you have Hepatitis? <br />_ Do you have Diabetes? <br />_ Any tendency to bleed excessively from minor cuts? <br />_ Do you have Epilepsy/Seizures of any kind? <br />_ Do you have an Autoimmune Disorder? <br />_ Do you currently or have you had Cancer? If yes, please explain <br />_ Do you have HIV? <br />__Do you have herpes infection at the procedure site? <br />_Do you have a history of allergic reactions to latex or antibiotics? <br />_History of hemophilia or other bleeding disorders? <br />_History of cardiac valve disease? <br />_Other risk factors for bloodborne pathogens? <br />Please indicate any other medical conditions: <br />Please include any Medications currently being <br />Doctor's Name and Number <br />Client Signature Date <br />Please contact the artist as soon as possible if you have any medical conditions listed on this form in order to prepare <br />and take the necessary precautions (at least a week prior to your appointment. Some health conditions may require <br />doctor's clearance. Thank you <br />