Name *

First Name

Last Name

DOB *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Number *

(###)

###

####

Have you had an allergic reaction to one of the following?

Latex Rubber

Antibiotics

Medication

Lidocaine

Have you ever had one of the following?

Retin A within the last 2 weeks

Prolonged bleeding

Diabetes

Artificial heart valves

Cardiac valve disease

Hemophilia or other bleeding disorder

Fainting spells or dizziness

Liver disease

HIV

Hepatitis

Cancer

Chemical or laser peel within 6 weeks

Alopecia

Fat injections, botox injections, collagen injections

Keloid scars

Healing problems

Herpes infection at the proposed procedure site