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site) or any open wounds or lesions? Y/ N <br /> — Do you bruise easily, swell or bleed easily? Y/ N <br /> — Do you use Retin-A, glycolic Acid, Vitamin C or other <br /> exfoliates? Y/ N <br /> — Do you have autoimmune disorder? Y/ N <br /> — Do you have a history of medication use or currently using <br /> medications? Y/ N <br /> — Do you have Trichotillomania? (Pulling of hair, eyebrows or <br /> lashes) ? Y/ N <br /> — Do you have any pre-existing nerve damage in THE AREA that I <br /> will be working on? Y/ N <br /> — Do you have tattoos? Y/ N <br /> — Are any of the colors in your tattoos) sensitive to sun or <br /> rise up in the sun? Y/ N <br /> — Are you currently tanned in the area (s) to be treated? Y/ N <br /> — Do you tint your eyebrows? Eyelashes? Y/ N <br /> — Have you had Botox to raise your eyebrows? Y/ N <br /> — Have you ever allergic reaction to a topical antibiotic? <br /> Y/ N <br /> — Have you ever an allergic reaction to Lidocaine? Y/ N <br /> — Do you have any reactions to cosmetics, latex, or seasonal Hay <br /> fever? Y/ N <br /> — When at the dentist, do you anesthetize easily? Y/ N <br /> — Have you had a chemical peel? Y / N What type? When? <br /> — Do you spend a lot of time in the sun? Y / N In a chlorinated <br /> pool? <br /> — Do you use sunscreen regularly? Y/ N <br /> — Have you had any facial cosmetic surgery? Y/ N <br /> — Have you had laser treatments? Y / N What TYPE? When? <br /> Is there anything I need to know about your health or healing <br /> that could complicate this procedure? <br /> If you are presently under a physician' s care for any condition, <br /> please describe: <br /> Physician' s Name: <br /> Address: <br /> Phone: <br /> I hereby certify that, to the best of my knowledge, all <br /> statements contained hereon are true. <br /> Client Signature: Date: <br /> Technician Signature: <br /> 4 <br />