COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

Name: Address; City: D131b: Referred By: CONFIDENTIAL MEDICAL PROFILE Date; State: zip. Cell Phone: To avoid unforeseen casnpiicatians, Please ansvver the following auestiansa Yes No Are you under the age of 18? Legal guardian initials: Yes No Have you had any aspirin or blood thinning products within the last 7 days? Yes No Have you had any mood altering drugs within the last 8 hours? Yes No Do you have any history of cold sores, herpes, or fever blisters? Yes No Are you sensitive to latex? Yes No Have yqu had a chemical or laser peel? If so, when? Yes No Do you have problems with healing? Yes No Have you had any previous problems with tattoos, or as has your physician advised you not to have a tattoo at this time? Yes No Are you currently undergoing radiation or chemotherapy? Yes No Are you currently using Retin-A or Alpha Hydroxy skin care products? Yes No Do you wear contact lenses? (If yes, I understand they must be removed before any eyeliner procedure and should not be replaced until the next day) - Yes No Are you allergic to any metals? Yes No Have you ever had any permanent make-up procedures before? Yes No Are you taking any anti-inflammatory medication or steroids? Yes No Are you suffering from withdrawal from caffeine products? Yes No Are you allergic to topical antibiotic preparations or desensitizers? O.E. polysporin, bacitracin, Neesoodd or "Caine" family of drugs or petroleum) Yes No Do you have a history of any skin diseases or remarkable skin sensitivities? Yes No Are you currently taking Vitamin A and/or E in any form? Yes No Are you pregnant or nursing? Yes No Are you required to take antibiotics during dental or invasive medical procedures? Alease circle any of the fo)lo��iing that may pertain to you: Heart Conditions Hepatitis/Jaundice HIV Allergies to makeup Kidney di Accutane treatment Dry eyes Shortness of breath Keloid or hypertrophy scars Keloid formation Refractive eye surgeryAlopecia Diabetes Autoimmune disorders sease Tendency to develop fever Blisters on lips Hyper -pigmentation (darkening of skin) Excessive bleeding from minor injuries Chest pains Glaucoma Epilepsyjseizures Stroke Ocular herpes Ca neerfanvtvne-i �iaase expiairf arty chocked GLeston and last aay eschar medical conditio7s and all n±eaications currently being taken: iiOitvFS Patna: 99-1237 Ulm ;m. zo,.