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Are you currently under medical care? ❑Yes ❑No <br /> Have you had any cosmetic injections in the last 3 months in the area to be treated? <br /> ❑Yes El No <br /> Have you had Botox/Dysport or any other fillers in the area to be treated in the last 2 <br /> weeks? ❑Yes ❑No <br /> Are you pregnant or breastfeeding? ❑Yes ❑No <br /> Do you have any allergies, including allergic reactions to latex or antibiotics? <br /> ❑Yes ❑No <br /> If yes, please list allergies here <br /> Do you have a history of herpes infection on the procedure site? ❑Yes ❑No <br /> Are you a hemophiliac, or do you have any other bleeding disorders? ❑Yes <br /> ❑No <br /> Do you take fish oil supplements or blood thinners? ❑Yes ❑No <br /> Do you have a history of diabetes? ❑Yes ❑No <br /> Do you have a history of heart conditions, including cardiac valve disease? <br /> ❑Yes ❑No <br /> Do you have high or low blood pressure? ❑Yes ❑No <br /> Do you have Hepatitis A, B or C? ❑Yes El No <br /> Are you HIV positive? ❑Yes ❑No <br /> Do you have any contagious diseases or risk factors for blood-borne pathogens? <br />