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Had undergone Botox treamrent <br />Please list down any medications you are taking: <br />Has or any family history of Diabetes <br />Has Hepatitis A B C D <br />Had Forehead/Brow Lift <br />r <br />Had Facelift Surgery - <br />( <br />r - <br />Has. a Hear t Condition <br />t' <br />f-' <br />I. -Ins Autoimmune disorder - `- <br />rr'• <br />Has, had, or any family history of having Cancer <br />= r <br />i } <br />--Had undergone Chemotherapy/ Radiation <br />r <br />C - <br />Taking or have taken aane-treatments. in the past 3 months. <br />Had a Tan treatment <br />Difficulty numbing with dental work - - <br />L` <br />{" <br />Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc. <br />Allergic reaction, to any medications <br />t". <br />: r <br />Allergies to metals, food, etc. <br />Do you use facial care treatments? <br />f` <br />r - <br />History of herpes infection -at the procedure site? <br />History of allergic reactions to latex? <br />i . <br />• r <br />History of allergic reactions to antibiotics? <br />History of hemophilia or other- bleeding disorders? <br />x <br />P` <br />History of cardiac valve disease? - <br />{s. <br />- i <br />Any other blood borne pathogen risk factors? -: <br />r <br />_ f`. ` <br />