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SKIN: Check all of the following that apply. <br /> Any other tattoos-Location: <br /> ❑ Age of tattoo: Any problems: <br /> ❑ Use of sunlamp/tanning bed/suntan outdoors ❑ Currently tanned in the area being treated. <br /> ❑ Currently use Retin A-Location: ❑ Currently using glycolic acid, AHA or Retinol? <br /> ❑ Injectables such as Restylane,Juvederm or other fillers? <br /> ❑ Ever had a chemical peel?When: ❑ Type of peel: <br /> ❑ Do you have a scar you want camouflaged? Age of Scar: <br /> ❑ Any keloid or hypertrophic scars?-Location: <br /> ❑ Do you bruise or bleed easily? ❑ Do you have healing problems? <br /> ❑ Other active skin disorders?Describe: <br /> GENERAL MEDICAL:Check all of the following that apply. <br /> ❑ Diabetes m ❑ Heart Palpitations <br /> ❑ High blood pressure 1:1 Mitral valve prolapse or valve implants <br /> E] Pregnant or nursing QJ__ ❑ Hemophilia or other clotting disorders c, <br /> ❑ Taken Accutane within the last 6 months <br /> 0,( ❑ Currently on blood thinners or anticoagulants such as Coumadin,aspirin, ibuprofin, alcohol? <br /> ❑ Autoimmune disorders-describe: <br /> Do you have a condition such as Hepatitis,HIV or undergoing treatment such as chemotherapy that could affect <br /> El <br /> healing??G �-- <br /> ❑ Seizures-describe: <br /> ❑ Current use of controlled substances-describe: <br /> Please list any surgeries: <br /> If you are planning cosmetic or other surgeries/procedures in the near future,describe: <br /> List all medications,prescription and non-prescription that you have taken in the last two weeks: <br /> If you are currently under a physician's care for any condition,describe: <br /> Physician's Name: City: Phone: <br /> This history has been reviewed by the technician and my questions have been satisfactorily answered. <br /> I have also received and reviewed a copy of the Pre-Procedure Information Sheet and the After Care Sheet.I <br /> understand them and agree to follow them. <br /> Signature: Date: <br />