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Initial I understand that it is my responsibility to book my touchup accordingly to the timeframe <br /> and each touch up fee is according to the time frame. <br /> Initial I understand there are NO guarantees and refunds will NOT be given. <br /> ***I have read and understand these risks listed above and they have been explained to me. I have <br /> answered the questionnaire accurately and that it has been explained to me, I accept full responsibility <br /> for any complications that may arise during or following the cosmetic procedure(s) to be performed at <br /> my request. <br /> Signature <br /> Medical History <br /> Are you pregnant or nursing?YES/NO <br /> Do you have epilepsy, hemophilia, anemia, iron deficiency, or any bleeding disorders?YES/NO If yes, <br /> what disorder? <br /> Do you have diabetes and use insulin?YES/NO <br /> 7 <br /> Do you smoke. Drink alcohol. SMOKE DRINK NONE <br /> Y / / <br /> Are you on Accutane?Or have you taken in within the last year?YES/NO <br /> Do you have cardiac valve disease?suffer from any heart condition?YES/ NO <br /> Are you on steroids or anti-inflammatory medications?YES/ NO <br /> Do you suffer from Hepatitis or other blood borne pathogen exposure or any communicable diseases? <br /> YES/NO <br /> Do you suffer from any medical or skin conditions: such as keloids, psoriasis or any open wounds or <br /> lesions at procedural site?YES/NO <br /> If yes what kind of skin conditions? <br /> Do you use Retin A,glycolic acid, vitamin C or other exfoliates YES/ NO <br /> Do you bruise, swell or bleed easily?YES/ NO <br /> Do you have an autoimmune disorder?YES/NO <br /> Do you have any existing tattoos?YES/ NO <br />