Consultation Form

Please fill out the consultation and consent forms prior to attending your appointment. Thank you.

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Consultation Form

ALLERGIES
Do you have any allergies? (i.e. Latex)
Have you ever had a reaction to anesthetics?
Have you ever had a reaction to antibiotics?
Have you ever had a reaction to Lidocaine?
Have you had an eye surgery?
Medical History
Survey
YesNo
Do you have any tattoos?
Are you Diabetic?
Do you bruise easily?
Are you currently pregnant or breastfeeding?
Do you have any heart conditions?
Does your skin swell easily?
Have you ever tested positive for HIV or Hepatitis?
Have you ever had a fever blister, cold sore, or canker sore?
Do suffer from a serious medical condition?
Medical History
Are you currently taking any medications, including immunosuppressant such as an anti-inflammatory or steroid?
Do you use anti-aging products that contain acids or Retinol A?
Do you use acne products (i.e. Proactive, Salicylic acid)
Are you able to take over-the-counter antihistamine? (i.e. Benadryl)
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