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Client Medical History Form <br /> Date: Birth Date: Name: <br /> Address: <br /> Phone: E-mail: <br /> Emergency Contact Person: Phone: <br /> Do you presently have or previously had any of the following: <br /> Yes No—History of MRSA <br /> Yes No—Botox(last treatment ) <br /> Yes No—Diabetes <br /> Yes No—Hepatitis(A, B, C, D) <br /> Yes No—Forehead/Brow Lift/Facelift <br /> Yes No—History of Herpes infection at the procedure site <br /> Yes No—Easy bleeding/history of Hemophilia or other bleeding disorders <br /> Yes No—Alcoholism <br /> Yes No—Abnormal Heart Condition,or cardiac valve disease <br /> Yes No—Take medication before Dental work <br /> Yes No—Chemical Peel (last treatment ) <br /> Yes No—Pregnant now/Breast feeding <br /> Yes No—Brow or Lash tinting <br /> Yes No—Autoimmune disorder <br /> Yes No—Autoimmune Disorder <br /> Yes No—Oily Skin <br /> Yes No—Cancer(year ) <br /> Yes No—Accutane or Acne treatment <br /> Yes No—Chemotherapy/Radiation <br /> Yes No—Tan by booth or sun <br /> Yes No—Tumors/Growths/Cysts <br />