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Do you have a history of Herpes infection at or near the procedure site? Yes/No <br />Do you have a history of allergic reactions to antibiotics? Yes/No <br />Do you have a history of hemophilia or any other bleeding disorders? Yes/No Do you <br />have a history of cardiac valve disease? Yes/No <br />PRESENT CONDITION / COVID49 QUESTIONNAIRE <br />Have you or anyone in your immediate circle conhacted or been close to individuals who have contracted <br />COVID-19 in the past 14 days? Yes/No <br />Have you traveled for vacation purposes in the last 14 days? Yes/No <br />Is anyone in your household on quarantine or exhibiting symptoms possibly related to <br />CO17 <br />ID-l9? Yes/No <br />Procedures penetrate skin and can cause discomfort. All procedures require sitting/laying flat for <br />extended amounts of time, up to four hours. Are you feeling healthy for this procedure today? Yes/No <br />Have you followed the necessary pre-procedure guidelines given to you by your artist? <br />Yes/No <br />FOR LIP PROCEDURES: <br />Have you ever had a cold sore? YES/NO If yes, please consult your physician for a prescription <br />of ZOVMAX capsules, an antibiotic which prevents cold sores. <br />Do you currently have any sign of Herpes outbreak at the procedure site? Yes/No <br />I agree that I have filled this out truthfully, and to the best of my know}edge. 1 understand that if the <br />answers provided are misleading or not truthful, my artist is not liable for any ill-effects to the client <br />caused by a permanent makeup work session. Clients will be required to update a new questionnaire with <br />each appointment indefinitely. <br />SIGNED DATE <br />