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YES NO Accutane or acne treatment? <br /> YES NO Chemotherapy/ Radiation? <br /> YES NO Tan by booth or salon? <br /> YES NO Tumors/ Growth/ Cysts? <br /> YES NO History of Herpes near or on the procedure area? <br /> YES NO Difficulty numbing with dental work? <br /> YES NO Taking blood thinners such as : Aspirin, Ibuprofen, Alcohol, Coumadin etc ? <br /> YES NO Allergic reaction to any medications such as Lidocaine, Tetra- Caine, Epinephrine, <br /> Derma- Caine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, Anto iotics, etc <br /> List of AllMedications being taken. <br /> YES NO Allergic to Latex? <br /> YES NO Allergies to metals, food, etc <br /> YES NO Any diseases or disorders not listed <br /> YES NO Do you use skin care products containing Retina A, Glycolic Acid, or Alpha Hydroxyl ? Please <br /> list any medications you are taking <br /> I agree that all the above information is true and accurate to the best of my <br /> knowledge. <br /> Signed Date <br />