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Medical Health Form <br />Name: <br />Address: <br />Date of Birth: _ -Occupation: <br />List all the medications you have been taking in the last 6 month <br />-lave you taken any of the following in the last 2 days; Aspirin. Ibuprof.�n, Alcohol? <br />Have you received chemotherapy or radiation treatment in the last yeas? --__-- <br />r lame of Doctor. <br />c;urgery <br />Allergies: have you ever had an allergic reaction to any of the follovrir g:Wuts <br />Latex Rubber -lair dyes <br />antibiotic ointments Metals <br />fAedication Foods Lidocaine <br />mugs Crayons Glycerine <br />P3ints <br />Anesthetics (which <br />Mer allergies <br />Ar? you presently pregnant or breast feeding? <br />MRI scan scheduled in the next 3 months <br />La3er or IPL scheduled in the next 3 months <br />H istory of herpes infection at the procedure site? <br />,--you are required to take antibiotics before seeing a dentist, you will reed to take <br />Entibiotics before a permanent makeup procedure. <br />