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Do you have any existing tattoos? YES / NO <br />Have you had Botox to raise your eyebrows? YES / NO <br />Do you have any allergies to latex? YES / NO <br />Have you had a chemical peel? YES / NO If yes, when? <br />Have you had laser treatments? YES / NO If yes, Where? When? <br />Any work done on your lips? (fillers, fat transfer, etc.) YES / NO If yes, how long ago <br />Do you have a history of cold sores at proposed site? YES / NO <br />Do you have a history of herpes infection at the procedure site? YES / NO <br />Any history of allergic reactions to antibiotics? YES / NO <br />List of current medications. <br />Do you require taking antibiotics prior to a surgery or dental procedures? YES / NO <br />Is there anything else I need to Know about your health or healing that could complicate this procedure? <br />***1 have answered correctly to the medical questions above to the best of my Knowledge and belief. <br />Signature Date <br />