Laserfiche WebLink
Client Medical History Form <br /> Date: <br /> Birth Date: <br /> Name: <br /> Address: <br /> Phone: <br /> E-mail: <br /> Emergency Contact Person: <br /> 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 />