Be sure to complete and submit the form below as well as the Disclosure & Consent form at least one week prior to your appointment. We suggest you submit it when you book your appointment. 

Health History

Please read and complete the following information carefully and in its entirety.

Are you now or have you been under the care of a physician within the last two years? If yes, please provide the physician's name, address, and phone number. *
Are you pregnant or nursing? *
Have you consumed alcohol in the last 24 hours? *
Do you use tobacco products? *
Do you have any tattoos? *
Do you bruise easily? *
Do you have metal alergies or sensitivity? *
Do you have problems healing? *
Do you have keloid scars? *
Do you use or have you used Accutane? *
Do you tan? *
Do you have any abnormal heart conditions? *
Do you have or get cold soars? *
Are you a hemophiliac? *
Do you have high or low blood pressure? *
Do you experience prolonged bleeding? *
Do you have circulatory problems? *
Do you suffer from dizzy spells or fainting? *
Have you ever had cancer? *
Have you ever been required to take antibiotics before undergoing a medical procedure? *
Are you sensitive to creams or lotions? *
Are you allergic to latex? *
Are you allergic to hair dyes, makeup, foods or have any skin allergies? *
Are you currently taking aspirin or ibuprofen? *
Do you have oily skin? *
Do you scar easily from minor injuries? *
Are you currently under treatment for depression? *
Have you ever undergone blepharoplasty (eyelid surgery)? *
Do you have tumors, growths or cysts? *
Do you have any autoimmune diseases?
Are you epileptic? *
Are you diabetic? *
Do you have hepatitis? *
Are you anemic? *
Have you experienced hypo pigmentation? (lack of pigment) *
Have you ever experienced hyper pigmentation from an injury? *
Do you use Retin-A, Glycolic Acid or other exfoliating products regularly? *
Do you have cosmetic fillers or botox? *

Are you now or have you been under the care of a physician within the last two years? If yes, please provide the physician's name, address, and phone number. *

Condition being treated:

List all medications you are currently taking, including Retin-A, Glycolic Acid, and Accutane.*

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