PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. |
Are you at least 18 years old or older? * |
YES |
NO |
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. * |
YES |
NO |
Have you, or anyone in your household, exhibited any signs or symptoms of illness in the 2 weeks prior to your appointment? * |
YES |
NO |
Have you, or anyone in your household, been around someone that was exhibiting signs or symptoms of illness in the 2 weeks prior to your appointment? * |
YES |
NO |
Are you or anyone in your household a healthcare worker who works in an emergency room, hospital or office setting where you are exposed for any length of time to individuals with Covid-19 or any other contagious viruses or illnesses? |
YES |
NO |
Have you, or anyone in your household, traveled to or from out of state or been on an airplane in the 2 weeks prior to your appointment? * |
YES |
NO |
Do you currently have any condition, unrelated to illness, that might cause you to cough or sneeze? (Allergies, Asthma or other lung disorders etc..) * |
YES |
NO |
Are you currently pregnant or breastfeeding? * |
YES |
NO |
Have you ever been diagnosed by a medical doctor as having allergies? * |
YES |
NO |
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? * |
YES |
NO |
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as
immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? * |
YES |
NO |
Do you have any heart conditions or take medications which thin the blood? * |
YES |
NO |
Are you currently using or have you recently used medications that contain a controlled substance? * |
YES |
NO |
Are you currently using any medications that weaken the immune system that fights infections? * |
YES |
NO |
Have you been diagnosed with jaundice within the past twelve months? * |
YES |
NO |
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? * |
YES |
NO |
Are you currently under the influence of any, or have you taken any illegal substances in the 24hours prior to your appointment? * |
YES |
NO |
Are you currently under the influence of, or have you consumed any alcoholic drinks in the 24hours prior to your appointment? * |
YES |
NO |
Pronouns that we should use for you
|
Name that we should call you, if different than legal name.
|