Confidential Medical Profile

Name *

First

Last

Email *

Occupation

Date of Birth

Phone Number

Gender

Are you over the age of 18?

Do you take fish oil?

Have you taken any mood-altering drugs in the last 12 hours? (i.e. Wellbutrin, Xanax, Prozac)

Do you have any history of cold-sores, herpes, or fever blisters?

Are you sensitive to Latex/Lidocaine/Epi?

Have you had a chemical or laser peel?

Do you have problems with healing?

Have you had any previous problems with tattoos?

Are you currently undergoing radiation or chemotherapy?

Are you currently taking any chemotherapy medications?

Are you currently using Retin-A or the like?

Do you wear contact lenses?

Are you allergic to any metal?

Have you had any previous permanent makeup/microblading?

Have you had tattoos before?

Are you taking any medications including an immunosuppressive, such as anti-inflammatory or steroids?

Are you allergic to topical anesthetics?

Do you have a history of skin disease or remarkable skin sensitivities?

In the last year have you had a baby?

Which of the following applies to you?

Are you required to take antibiotics during dental or invasive medical procedures?

Do you have any drug allergies?

Are you currently taking medication for high or low blood pressure?

Have you had frequent sun exposure or used tanning beds?

Have you consumed alcohol today?

Did you work out today?

What skin care do you use?

Please explain any checked question, list any other medical conditions or allergies, and list all your medications

Have you had COVID-19?

Have you had the COVID-19 Vaccine?

Signature

Date / Time

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