Laserfiche WebLink
O History or epilepsy seizures,fainting,or narcolepsy <br /> ❑ Blepharoplasty(eyelid surgery) <br /> O Difficulty numbing with dentalwork <br /> O Allergic reaction to any numbing medications such as Lidocaine,Tetracaine,Epinephrine.Dermacaine,Benzyl alcohol,Carbopol.Lecithin. <br /> Propylene glycol.Vitamin E Acetate,etc. <br /> 0 LipfiLLem/Restylane/Juvederm <br /> O Botox <br /> O Do you use skin care products containing Retin-A,glycolic acid or alpha hydroxyl? <br /> O Cancer <br /> O History of allergic reactions to antibiotics <br /> Q Allergies to latex <br /> Q Chemical Peel <br /> O Pregnant now/breastfeeding now <br /> 0 Autoimmune disorder <br /> Alcholism <br /> O Chemotherapy/Radiation <br /> CD Tumors/Growths/Cysts <br /> O Cold sores/fever blisters ever? <br /> Forehead/browlift <br /> O Face lift <br /> 0 Contact lenses on now <br /> O Accutane or acne treatment <br /> O Brow henna or lash tinting recently <br /> O Oily skin <br /> Q Tan by booth or sun <br /> O Skin diseases or lesions? <br /> O Taking anticoagulants(any meds that thin your blood)such as:Aspirin,Ibuprofen,Tylenol,Coumadin,etc. <br /> O Any diseases or disorders not listed: <br /> Please list medication or vitamins you're presently taking: <br />