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CLIENT PERSONAL RECORD & MEDICAL HISTORY <br /> First Name' <br /> Last Name' <br /> Street Address <br /> City <br /> State <br /> Zip <br /> Date of birth <br /> 1 <br /> Gender <br /> MEDICALHISTORV <br /> Check all that apply: <br /> ❑ Allergies to Latex ❑ Allergies to Lidocaine <br /> ❑ Keloid Scars ❑ Diabetes <br /> ❑ Cold Sores/Shingles ❑ Iron Deficiency/Anemia <br /> ❑ Hemophilia ❑ Hypoglycemia <br /> ❑ Contact Lenses ❑ Skin Peel <br /> ❑ Planning on having a surgical brow/face lift? <br /> ❑ Do you have old permanent makeup? <br /> Check all that apply: <br /> ❑ AIDS(HM ❑ Pregnancy <br /> ❑ Heart Problems ❑ Hepatitis/Jaundice <br /> ❑ Accutane ❑ Blood Thinners <br /> ❑ Bleeding Disorder ❑ Skin Disordens) <br /> ❑ Botox <br /> Please List any current medications: <br />