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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? <br />Do you take Antidepressants or mood -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 <br />steroids? <br />_ Are you allergic to topical antibiotics? <br />e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or petroleum-based products <br />(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 />Please indicate any other medical conditions: <br />Doctor's Name and Number <br />Client Signature <br />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 />