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Lodi Micro Clinic <br /> Medical Questionnaire <br /> Name: <br /> Are you pregnant? Yes or No <br /> Do you have a history of herpes infection at the procedure site? Yes or No <br /> Do you have a history of diabetes? Yes or No <br /> Do you have a history of allergic reactions to latex? Yes or No <br /> Do you have a history of allergic reactions to antibiotics? Yes or No <br /> Do you have a history of hemophilia or other bleeding disorders? Yes or No <br /> Do you have a history of cardiac valve disease? Yes or No <br /> List current medications? <br /> Do you require antibiotics prior to surgery or dental procedures? Yes or No <br /> Do you have any other risk factors for bloodborne pathogens? Yes or No <br /> Are you at least 18 years old? Yes or No <br /> Microblading is cosmetic tattooing, it is done by manually depositing pigment into the <br /> second layer of the skin (dermis). <br /> I understand the Inks are not FDA approved and health consequences are unknown <br /> Signature: date: <br />