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[Z 'ON Wd6 1Z ti[H U '130 ;w1i paAI ;3;d SKIN: Check-a]1 of the followinv that apply. Any other,tattoos-Location: ❑ Age of tattoo: Any problems: ❑ Use of sunlarnpltanning bed/suman outdoors ❑ Currently tanned in the area being treated_ ❑ Currently use Retin A-Location: C Currently using glycolic acid, AHA or Retinol? ❑ Injectables such as Restylane,7uvederm or other fillers? ❑ Ever had a chemical peel?When: ❑ Type of peel: C Do You have a sear you want camouflaged?Age of Scar: E Any keloid or hypertrophic scars? -Location: ❑ Do you bruise or bleed easily? ❑ Do you have healing problems? ❑ Other active skin disorders? Describe: GENERAL MEDICAL: Check all of the following that apply. Diabetes ❑ Heart Palpitations C High blood pressure ❑ Mitral valve prolapse or valve implants C Pregnant or nursing ❑ Hemophilia or other clotting disorders r- Taken Accutane within the last 6 months ❑ Cardiac Valve Disease ❑ Currently on blood thinners or anticoagulants such as Coumadin,aspirin, ibuprofin, alcohol? ❑ Autoimmune disorders-describe: Do you have a condition such as Hepatitis, 1711V or undergoing treatment such as chemotherapy that could affect ❑ healing? ❑ Are you required to take antibiotics prior to surgery or dental procedures? ❑ Seizures-describe: Cl Current use of controlled substances-describe: Please list any surgeries: If you are planning cosmetic or other surgeries/procedures in the near future, describe: :List all medications,prescription and non-prescription that you have taken in the last two weeks: If you are currently under a physician's care for any condition,describe: Physician's Name: City: Phone: This history has been reviewed by the technician and my questions have been satisfactorily answered. I have also received and reviewed a copy of the Pre-Procedure Information Sheet and the After Care Sheet.I understand them and agree to follow them. Signature: Date: 0 L'd t99 L 6£Z60Z aAilouaolnV uolsioeid dg L:ZO t L LZ 100