Medical History Form

When is your birthday? Date and Month. Year not required. Example: 1 October

How did you hear about us?

Are you currently having any kind of treatment with your doctor or a specialist?

Any recent BOTOX or Fillers?

Any recent treatment for Forehead/Brow Lift /Facelift/Novastring?

Any recent Chemical/ Laser Peel or any skin treatments?

Recent Microblading or other permanent make up or tattoo?

History of MRSA (methicillin-resistant Staphylococcus aureus)

Diabetes (Type 1 OR Type 2)

Hepatitis – A, B, C or D

Do you suffer with any form of Abnormal Heart Condition?

Are you taking medications including immunosuppressive, such as anti-inflammatory or steroids?

Are you pregnant or nursing?

Do you have or ever had any type of Cancer?

Are you currently or have you ever undergone Chemotherapy/Radiation?

Any Tumors/ Growth/ Cysts?

History of skin diseases or remarkable skin conditions or sensitivities?

Do you suffer with Herpes Simplex? (cold sores)

Are you currently taking Accutane or acne treatment?

Are you currently taking Vitamin A or Vitamin E in any form?

Are you taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin currently or in the last 7 days?

Any Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, adverse reaction to dentist treatment, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, other?

Any Allergies to metals, latex, food, topical anesthetic, adhesives or any other?

Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl?

Have you taken any mood- altering drugs in the last 8 hours?

Do you have problems with healing?

Have you consumed alcohol within the last 24 hours?

Please list any medications you are taking (including Natural Supplements)

Are there any other medical conditions that we should be aware of?

If you are out in the sun, do you?

Do you have any of the following?

I agree that all the above information I have given is true and accurate to the best of my knowledge.

I accept that it is my responsibility to consult with my physician and obtain the appropriate doctors note for any contraindication that I believe may exist prior to undergoing any treatment procedures.

Your Signature

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