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Microblade Aesthetics <br /> Brows by Crystal <br /> Medical History Form <br /> Today's Date: Birth date: <br /> Name: <br /> Home Address: <br /> Work Address: <br /> Home/Cell Phone: Work Phone: <br /> Employer: Occupation: <br /> Are you now or have been under the care of a physician within the last two years? <br /> Ifyes,please provide Physician's Name, address, and phone number: <br /> Person to contact in an emergency: <br /> Name <br /> Phone Number: <br /> List all medications you are currently taking,including Retin A,Glycolic Acid,and Acutane: <br /> List any drug,makeup,skin or food allergies (i.e.latex,soap,or antibiotics): <br /> Have you recently undergone a skin peel? <br /> What products do you use for skin care? <br /> Do you have any of the following conditions (answer YES or NO): <br /> Abnormal Heart Condition Eye surgery or injury <br /> Cold Sores Blepharoplasty(eyelid surgery) <br /> Herpes Simplex (procedure site) Visual Disturbances <br /> Hemophilia and/or any other bleeding disorder <br /> Do you require antibiotics before surgery or <br /> dental surgery procedures <br /> Cancer High or Low Blood Pressure <br /> Tumors/Growths/Cysts <br /> Prolonged Bleeding Chemotherapy/Radiation <br /> Circulatory Problems Are you pregnant? <br /> Epilepsy Hepatitis <br /> Diabetes Do you wear contact lenses? <br /> Fainting Spells/Dizziness Keloid condition <br /> Cataracts Cardiac Valve Disease <br /> Glaucoma Eye Drops or Ocular Medications <br /> Dry Eye Hyper-Pigmentation <br /> Corneal Abrasions Currently taking Aspirin <br /> Signature Date <br />