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SKIN": Check all the hollowing that apply: <br /> Anv other tattoos—location: <br /> Age of tattoo: any problems: <br /> Use of sunlamp/tanning bed suntan outdoors <br /> Are you currently tan in the area to be treated <br /> Currently use Retin A—location: <br /> Currently using glycolic acid or other AHA skin products <br /> I-Iave you ever had a chemical peel'? When'? <br /> What type of peel'? <br /> Do you have a scar you want camouflaged'? Age of scar: <br /> Any keloid or hypertrophic scars—location: <br /> Bruise or bleed easily <br /> llealing problems <br /> Other active dermatoligical disorders.Describe: <br /> GENERAL MEDICAL: Check all of the following that apply: <br /> High blood pressure <br /> Diabetes <br /> Currently on blood thinners or anticoagulants such as Aspirin,Ibuprofin,Coumadin,Alcohol <br /> Hemophilia or other clotting disorders <br /> Mitral valve prolapse or valve implants <br /> Heart Palpitations <br /> Taken Accutane within the last 6 months <br /> Pregnant or nursing <br /> Ever had Hepatitis—When? <br /> Seizures—describe: <br /> Autoimmune disorders <br /> Please list any surgeries: <br /> If you are planning cosmetic or other surgery in the near future, describe: <br /> List all medications,prescription and non-prescription, that you have taken in the last two weeks: <br /> if you are currently under a physician's care for any condition. describe: <br /> Physicians name : City: Phone: <br /> '['his history has been reviewed by the technician and my questions have been satisfactorily answered. <br /> I have also received and reviewed a copy of the Pre-Procedure Information Sheet and the after Care Sheet. i understand <br /> them and agree to follow them. <br /> Signature: Date: <br /> c_'opynghi.socici}of Permanent Cosmcuc Professionals 9,95 <br />