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0 <br /> Yes No—Difficulty numbing with dental work <br /> Yes No—Taking blood thinners such as:Aspirin, Ibuprofren, alcohol, Coumdan, ect. <br /> Yes No—Allergic reaction to any medication such as Lidocaine,Tetracaine, Epinephrine, Dermacaine, <br /> Benzyl Alchohol,Carbopol, Lecithin, Propylene glycol,Vitamin E Acetate, ect. <br /> List: <br /> Yes No—Allergies to metals,food,or latex,etc. <br /> Yes No—Any diseases or disorders not listed: <br /> Yes No—Do you use skin care products containing Retin-A,glycolic acid or alpha hydroxyl? Please list <br /> medication or vitamins you're presently taking: <br /> I agree that all the above information is true and accurate to the best of my knowledge. <br /> Signed: <br /> Date: <br />