PRE-APPOINTMENT QUESTIONNAIRE

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

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MEDICAL HISTORY

PLEASE SELECT ALL THAT APPLY (CURRENTLY OR IN THE PAST) *
.
YESNO
HISTORY OF MRSA
HERPES INFECTION
DIABETES
CHEMOTHERAPY/RADIATION
HEPATITIS ABCD
HIV/AIDC
CANCER
HEMOPHILIA
BLEEDING DISORDER
ABNORMAL HEART CONDITION
CARDIAC VALVE DISEASE
USE PRODUCTS RETINOIDS/GLYCOLIC ACID/ALPHA HYDROXYL
ACCUTANE OR ACNE TREATMENT
TUMORS/GROWTHS/CYSTS
TAKING BLOOD THINNERS (ASPIRIN, IBUPROFEN, ETC.)
PREGNANT OR BREAST FEEDING
MEDICATION ALLERGIES
OTHER ALLERGIES
OTHER DISEASES NOT LISTED
BOTOX
CHEMICAL PEEL
LASER HAIR REMOVAL
FACELIFT
FOREHEAD LIFT OR BROW LIFT
BROW TINT/LASH LIFT/LASH TINT
MICROBLADING, MICROSHADING, OR OTHER EYEBROW TATTOO
PERMANENT EYELINER OR EYELID TATTOO
LIP CONTOUR/LIP BLUSH/LIPLINER TATTOO
MICRONEEDLING OR MICRODERMABRASION
RECENT WAX, SUGARING, THREADING, OR OTHER HAIR REMOVAL

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