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Have you had Botox to raise your eyebrows?YES/NO <br /> Do you have any allergies to latex?YES/NO <br /> Have you had a chemical peel?YES/ NO If yes, when? <br /> Have you had laser treatments?YES/ NO If yes,Where?When? <br /> Any work done on your lips? (fillers, fat transfer, etc.)YES/ NO If yes, how long ago <br /> Do you have a history of cold sores at proposed site?YES/ NO <br /> Do you have a history of herpes infection at the procedure site?YES/NO <br /> Any history of allergic reactions to antibiotics?YES/NO <br /> List of current medications. <br /> Do you require taking antibiotics prior to a surgery or dental procedures?YES/ NO <br /> Is there anything else I need to know about your health or healing that could complicate this procedure? <br /> ***I have answered correctly to the medical questions above to the best of my knowledge and belief. <br /> Signature Date <br />