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Medical Information <br />Yes No <br />Do you have a history of herpes infection at the proposed procedure <br />site? (Cold sores or fever blisters. <br />Are you pregnant or nursing? <br />Do you wear contact lenses? <br />Do you have glaucoma or other eye disease, disorder or had any <br />eye trauma? <br />Do you have epilepsy, haemo hilia or other bleeding disorders? <br />Have you had a vision correction procedure such as RK or Lasik <br />surgery in the last 3 months? <br />Are you considering having vision correction procedures in the next <br />2 months? <br />Are you prone toe a infections (i.e., conjunctivitis/ ink eye)? <br />Are you on a blood thinning medication? <br />Do you take aspirin? Y/N Do you smoke? Y/N Drink alcohol? Y/N <br />Are you on Accutane, or have you taken it within the last year? <br />Do you have cardiac valve disease? <br />Do you suffer from any heart conditions? <br />Prior to dental or surgical procedures, do you receive antibiotic <br />therapy? <br />Are you on steroids or anti4nflammator medications? <br />Do you suffer from Hepatitis, or other risk factors for bloodborne <br />pathogen exposure or any communicable disease? <br />I have been advised of any medications and procedures necessary <br />to promote the satisfactory healing of my procedure. <br />Do you have diabetes and do you use insulin? <br />