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Has or any family history of Diabetes <br />i <br />Has Hepatitis A D C D r'. f <br />Had Forehead/Brow Lift C r <br />i <br />Had Facelift Surgery C r <br />Has a Heart Condition r r <br />I <br />I <br />Has Autoimmune disorder r r <br />Has, <br />had, or any family history <br />of having Cancer <br />: r• <br />', C <br />Had <br />undergone Chemotherapy/ <br />Radiation <br />r <br />r' <br />Taking or have taken acne treatments in <br />the past 3 months <br />f`- <br />f" <br />Had a Tan treatment <br />f <br />r <br />Difficulty numbing with dental work r` r' <br />Taking blood thinnees such as: Aspirin, Ibuprofen, Alcohol, Cotvnadih etc i" f"' <br />Allergic reaction to any medications <br />C <br />r' <br />Allergies to metals, food, etc, <br />r <br />f <br />Do you use facial care treatments? <br />History of herpes? <br />r <br />History of allergic reactions to latex? <br />r <br />r' <br />History of allergic reactions to antibiotics?fes', <br />C <br />History of hemophilia or other bleeding disorders? <br />r. <br />fes• <br />History of cardiac valve disease? <br />r <br />i <br />fes' <br />Any other blood borne pathogenrisk factors? <br />r'. <br />Please list down any medications you are taking: <br />