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Medical History

Do you presently have or previously had any of the following:

Lip fillers/ Restylane/ Juve derm:
Blepharoplasty (eyelid surgery):
Brow lift:
Face lift:
Eye surgery/ injury/ corneal abrasion:
Contact lenses now:
Pregnant now/ breast feeding now:
Oily skin:
Tan by booth or sun:
Taking blood thinners such as Aspirin, Ibuprofen, alcohol, Coumadin, etc.:
Allergies to metals, food, etc.:
Cold Sores/ Fever blisters ever?
Hepatitis (A, B, C, D):
Easy bleeding:
Abnormal hear condition:
Chemical peel (last treatment):
Brow or lash tinting:
Accutane or acne treatment:
Difficulty numbing with dental work:
Allergic reaction to any medications such as Lidocaine, Benzyl alcohol, Vitamin E Acetate, etc.:
Any diseases or disorders not listed:
Do you use skin care products containing Retin-A, glycolic acid or alpha hydroxyl?

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

Thanks for submitting!

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