PRE-APPOINTMENT QUESTIONNAIRE

YOU MUST BE 21 YEARS OLD OR OLDER TO DO THE PROCEDURE

FIRST NAME *

LAST NAME *

BIRTHDATE * +

CITY OF RESIDENCE *

PHONE NUMBER *

EMAIL ADDRESS *

MEDICAL HISTORY

PLEASE SELECT ALL THAT APPLY (CURRENTLY OR IN THE PAST) *

	.
	YES	NO
HISTORY OF MRSA	YES	NO
HERPES INFECTION	YES	NO
DIABETES	YES	NO
CHEMOTHERAPY/RADIATION	YES	NO
HEPATITIS ABCD	YES	NO
HIV/AIDC	YES	NO
CANCER	YES	NO
HEMOPHILIA	YES	NO
BLEEDING DISORDER	YES	NO
ABNORMAL HEART CONDITION	YES	NO
CARDIAC VALVE DISEASE	YES	NO
USE PRODUCTS RETINOIDS/GLYCOLIC ACID/ALPHA HYDROXYL	YES	NO
ACCUTANE OR ACNE TREATMENT	YES	NO
TUMORS/GROWTHS/CYSTS	YES	NO
TAKING BLOOD THINNERS (ASPIRIN, IBUPROFEN, ETC.)	YES	NO
PREGNANT OR BREAST FEEDING	YES	NO
MEDICATION ALLERGIES	YES	NO
OTHER ALLERGIES	YES	NO
OTHER DISEASES NOT LISTED	YES	NO
BOTOX	YES	NO
CHEMICAL PEEL	YES	NO
LASER HAIR REMOVAL	YES	NO
FACELIFT	YES	NO
FOREHEAD LIFT OR BROW LIFT	YES	NO
BROW TINT/LASH LIFT/LASH TINT	YES	NO
MICROBLADING, MICROSHADING, OR OTHER EYEBROW TATTOO	YES	NO
PERMANENT EYELINER OR EYELID TATTOO	YES	NO
LIP CONTOUR/LIP BLUSH/LIPLINER TATTOO	YES	NO
MICRONEEDLING OR MICRODERMABRASION	YES	NO
RECENT WAX, SUGARING, THREADING, OR OTHER HAIR REMOVAL	YES	NO

PLEASE LIST ANY MEDICATIONS OR SUPPLEMENTS YOU ARE TAKING (INCLUDING BEING
PRESCRIBED ANTIBIOTICS PRIOR TO DENTAL OR SURGICAL PROCEDURES)

PLEASE LIST ANY OTHER KNOWN REACTIONS OR SENSITIVITIES (INCLUDING ALLERGIC
REACTIONS TO LATEX OR ANTIBIOTICS)

* Notice that tattoo inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown.

COVID 19-LIABILITY AND RELEASE WAIVER

The World Health Organization has declared the novel Coronavirus (COVID-19) a global pandemic. The
government has set recommendations, guidelines, and prohibitions due to the transmissibility of the
virus. Please review and the following and sign this waiver to verify your understanding and agreement
to the following disclosures.

I have NOT experienced symptoms of fever, fatigue, cough, or difficulty breathing or any other symptoms relating to COVID-19 within the last 14 days. *

Agree

Disagree

I, as well as all members of my household, have NOT traveled internationally or visited any area that was reported to be highly affected by COVID-19 within the past 30 days. *

Agree

Disagree

I, as well as all members of my household, have NOT been diagnosed or tested positive for COVID-19 within the last 30 days. *

Agree

Disagree

I, as well as all members of my household, have NOT knowingly been exposed to any individuals who were diagnosed or tested positive for COVID-19 within the last 30 days. *

Agree

Disagree

I understand the risks involved and hereby release, waive, and discharge the organization, its board, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19. *

Agree

Disagree

If vaccinated - please indicate the date of your last vaccination or booster. +

SIGNATURE *

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