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• • <br /> Client Medical History Form <br /> Date Birthdate <br /> Name <br /> Address <br /> Phone <br /> Emergency Contact <br /> Email <br /> Do you have or previously had any of the following: (Circle YES or NO) <br /> YES NO History of MRSA <br /> YES NO Botox(Last Treatment ) <br /> YES NO Diabetes <br /> YES NO Hepatitis A B C D <br /> YES NO Forehead/ Brow Lift <br /> YES NO Easy Bleeding <br /> YES NO Facelift <br /> YES NO Alcoholism <br /> YES NO Abnormal Heart Condition or Cardiac Valve Disease <br /> YES NO Take medication before dental work <br /> YES NO Chemical Peel (Last Treatment <br /> YES NO Pregnant Now—Breastfeeding Now <br /> YES NO. Brow Lash Tinting <br /> YES NO Autoimmune Disorder <br /> YES NO Oily Skin <br /> YES NO Cancer(Year ) <br /> YES NO Accutane or Acne Treatment <br /> YES NO Chemotherapy/ Radiation <br /> YES NO Tan by booth or salon <br /> YES NO Tumors/Growth/Cysts <br /> YES NO Difficulty numbing with dental work <br /> YES NO Taking blood thinners such as: Aspirin, Ibuprofen, alcohol, coumadin, etc. <br /> YES NO Allergic reaction to any medications such as Lidocaine,Tetracaine, Epinephrine, Dermacaine, <br /> Benzyle Acohol, Carbopol, Lecithin, Propylene Glycol.Vitamin E Acetate, etc. <br /> YES NO Allergic to metals,food, etc <br /> YES NO Any diseases or disorders not listed <br /> YES NO Do you use skin care products containing Retin A, Glycolic Acid, or Alpha Hydroxyl? <br /> YES NO History of Herpes infection at the procedure site. <br /> YES NO History of allergic reactions to latex and antibiotics <br /> YES NO Require antibiotics prior to surgery or dental procedures <br /> YES NO Any other risk factors for blood borne pathogens <br /> Please list any medications you are taking <br /> I agree that all the above information is true and accurate to the best of my knowledge. <br /> Signed Date <br />