Review my policies and care pages before your appointment  Links below.

MEDICAL HISTORY QUESTIONNAIRE

Name
MM slash DD slash YYYY
Emergency Contact
Have you had any cosmetic surgery during the last year?(Required)
Have you had any cosmetic injectables or fillers in the face within the last month?(Required)
Do you have any additional allergies such as to metals, soaps, cosmetics or alcohol?(Required)
Do you use any medications that might affect the healing of the body art you wish to receive?(Required)
Do you have any other medical or skin conditions that affect the outcome of your procedure?(Required)
Do you have a history of herpes at the procedure site?(Required)
Do you have any other medical or skin conditions that affect the outcome of your procedure?(Required)
Have you ever been prescribed antibiotics prior to dental or surgical procedures?(Required)
Do you have any cardiac valve disease?(Required)
Is there any information you feel you should provide to the body art practitioner?(Required)
Other medical conditions?(Required)
Please check any conditions listed below that apply to you.
I have read and understand the policies and information regarding pre-post care procedures.(Required)