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Medical History Form: Date:--J--J— <br /> Name: <br /> ate:_J—JName: <br /> Address: <br /> City/State/Zip: Email: <br /> Phone: Cell: <br /> Birthday: Age: Are you 18 or older? YES NO <br /> Medical History <br /> Have you had or have you ever been diagnosed for: (Please circle all that apply) <br /> Heart Attack Diabetes Herpes <br /> Pacemaker Seizures HIV <br /> High Blood Pressure Metal Implants Tumors or Cysts <br /> Liver or Kidney Disorders Botox Muscular Conditions <br /> Chronic Eye Problems Collagen Injections Immune Disorders <br /> Restylane Injections Cancer Herpes infection(at procedure site) <br /> Hemophilia Other Bleeding Disorders Cardiac Valve Disease <br /> Are you allergic to Latex? YES NO <br /> Are you allergic to any antibiotics?YES NO(if yes please list): <br /> List any allergies you may have: <br /> List any skin disorders or skin allergies: <br /> List any plastic surgery you have had: <br /> Are you required to take any antibiotics prior to surgery or Dental procedure? <br /> List any rick factors for blood borne pathogens: <br /> Do you hyper pigment?YES NO Do you bruise easily?YES NO <br /> Are you currently under a physician's care?YES NO <br /> If so,for what reason? <br /> List all medications you are currently taking (including muscle relaxants): <br /> Have you used Retin A or Accutane with in the year? When? <br /> Are you or could you be pregnant?YES NO <br /> Do you smoke?YES NO How much? <br /> Alcohol intake? Stress Level: <br /> Are you presently on a diet? <br /> How much water do you drink daily? <br /> Have you ever has a chemical peel, laser resurfacing, or other laser treatments? <br /> Date: Procedure: <br /> What products are you currently using on your skin? <br /> List any surgeries within the last 5 years: <br /> I attest to the fact that all of the above is true and that I am not aware of any medical situation that might affect my treatment. <br /> Signature: Print: Date: <br />