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Medical Information <br />Yes No <br />Do you have any reactions to cosmetics, latex, or seasonal hay fever? <br />When at the dentist, do you anestitize easil ? <br />.Are you presently using any eyelash enhancing products? <br />Have you had a chemical peel? What type? When? <br />Do you spend a lot of time in the sun? Y/N In a chlorinated pool? <br />Do you use sunscreen regularly? <br />Have you had any facial cosmetic surgery? When? <br />Are you happy with the result <br />Are you planning on facial surgery in the near future? <br />Have you had laser treatments? Y/N What type? When? <br />Is there anything I need to know about your health or healing that could <br />complicate this procedure? <br />If you are presently under a physicians care for any condition, please describe: <br />Physician's <br />Phone: <br />I hereby certify that, to the best of my knowledge, all statements contained <br />hereon are true. <br />Client Signature: <br />Technician Signature: <br />t• <br />te: <br />D <br />