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Client Medical History Form <br /> Date Birth Date AReDLor|D# <br /> Name: <br /> Address: City StateZ/p______ <br /> Phone #_ Email <br /> Emergency contact person Phone <br /> Do you presently have or previously had any of the following: (Circle yes or no) <br /> Yes No History of MRSA <br /> Yes 0oBotox (last treatment <br /> _______\ <br /> Yes No Diabetes <br /> Yes NoHepatitis (4,8,[,D} <br /> Yes NuForehead/Brow lift <br /> Yes NoEasy bleeding <br /> Yes NoFace lift <br /> Yes NoAlcoholism <br /> Yes 0oAbnormal Heart Condition <br /> Yes NoTake meds before Dental work <br /> Yes NoChemical Peel (last treatment <br /> _______) <br /> Yes NoPregnant now/ Breast feeding now <br /> Yes NoBrow orLash tinting <br /> Yes No Autoimmune Disorder <br /> Yes 0oOily Skin <br /> Yes NoCancer year <br /> _____ <br /> Yes NoAccutane o,acne treatment <br /> Yes NoChemotherapy/ Radiation <br /> Yes No Tan by booth or sun <br /> Yes No Tumors/Growths/Cysts <br /> Yes No Difficulty numbing with dental work <br /> Yes No Taking blood thinnners such as: Aspirin, lbuprofen, alcohol, Cournadin, ect. <br /> Yes No Allergic reaction to any medications such as Liclocaine,Tetracaine, Epinephrine, Dermacaine, <br /> Benzyl alcohol, Carbupo|, Lecithin, Propylene glycol,Vitamin EAcetate, ec1. <br /> List <br /> Yes No Allergies to metals,food, ect. <br /> Yes NoAny diseases ordisorders not listed: <br /> Yes No Do you use skin care products containing Retin-A,glycolic acid or alpha hydroxyl? <br /> Please list medication orvitamins you're presently taking: <br /> \ agree that all the above information istrue and accurate tVthe best ofmyknowledge. <br /> Signed: Date <br /> Color Selected for client: <br />