::WAX :: LA | CONFIDENTIAL MEDICAL PROFILE
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CONFIDENTIAL MEDICAL PROFILE

Are you under 18?
YESNO

Are you allergic to any metal?
YESNO

Have you had any aspirin or blood thinners in the past week?
YESNO

Have you ever had any semi-permanent makeup procedures before?
YESNO

Any mood-altering drugs within the last 8 hours?
YESNO

Are you on any immunosuppressive medications such antiinflammatories or steroids? Do you have a history of cold sores, herpes, or fever blisters?
YESNO

Are you allergic to topical antibiotic preparations or desensitizers?
YESNO

Are you sensitive/allergic to latex?
YESNO

Is there any history of skin diseases or remarkable skin sensitivities?
YESNO

Have you had a chemical peel or laser?
YESNO
If so, when?

Are you currently taking vitamin A or E in any form?
YESNO

Do you have problems healing?
YESNO

Are you pregnant or nursing?
YESNO

Are you currently undergoing radiation or chemotherapy?
YESNO

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

Are you currently using any retin-a or alpha-hydroxy skin care products?
YESNO

Do you wear contact lenses? (If yes, they must be removed during the procedure and should not be replaced until the next day.)
YESNO

Previous problems with tattoos or has your physician advised you not to have a tattoo at this time?
YESNO

Please list all medications and/or dietary supplements you are currently taking:

Please select any of the following medical conditions/treatments/procedures you currently have or have had in the past:

Heart ConditionsAllergies To MakeupAccutaneTreatment Dry EyesDiabetesStrokeChest PainsAlopeciaRefractive Eye surgeryGlaucomaTrichotillomaniaKeloidEpilepsy/SeizuresShortness Of BreathAutoimmune DisorderCancer (Any)Hepatitis/JaundiceHIVKidney DiseaseBlisters On The LipOcular HerpesTendency To Develop FeverHyperpigmentationHypopigmentationTendency To Bleed Excessively From Minor Injuries

By signing below, I acknowledge, understand, and agree that the information provided on this form is accurate and complete to the best of my knowledge and that Alexis Dallinger (aka Alexis B Brows) and her contractors are not responsible for complications or problems that may arise due to any incorrect or omitted information on this form.

(Please use your mouse cursor or touchscreen device to sign in the box below.)