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PATIENT IN-TAKE

This in-take is required yearly for all procedures. 

Gender Assigned At Birth
What services are you receiving?
Allergies: Check all that apply and describe any reactions you have experienced.
1. Are you pregnant or nursing?
2. Have you had any alcohol in the last 24 hours?
3. Have you ever had cold sores or fever blisters?
4. Have you had a laser or chemical peel within 6 months?
5. Have you ever had any pemanent cosmetics or tattoos?
6. Do you bruise easily for no obvious reason?
7. Do you routinely use Retin-A, glycolic, or other exfoliating products?
8. Do you wear contact lenses?
9. Are you allergic or sensitive to any metals? For instance, metals used in jewelry?
10. Do you have any problems healing?
11. Is your skin oily?
12. Do you use tobacco?
13. Do you have any heart conditions?
14. Are you diabetic?
15. Do you have any autoimmune disorders?
16. Are you sensitive or allergic to hand creams or body lotions?
17. Do you have your lips injected with filler materials?
18. Do you have Botox / Neurotoxin injections?
19. Do you menstruate?
20. Do you hyper-pigment (Tendency to develop dark spots on the skin from wounds or sun)?
21. Do you tend to develop keloid or hypertrophy scars?
22. Do you scar easily from minor injuries?
23. Do you have any seizure related conditions?
24. Do you tend to faint or become dizzy?
25. Do you bleed excessively from minor cuts?
26. Do you have prosthetic implants?
27. Do you consume aspirin daily?
28. Are you under treatment for depression?
29. Do you have any type of herpes?
30. Are you sensitive to petroleum-based products?
31. If you have had permanent cosmetics or tattoos, did you have any problems with heaing afterwards?
32. Are you undergoing radiation or chemo-therapy treatments?
33. Are you now, or have you ever been on the acne treatment Accutane?
34. Are you wearing a pacemaker?
35. Do you take prescription medications?
36. Are you anemic?
37. Do you have a history of skin sensitivities?
38. Do you have any medical conditions that have resulted in a medical professional requiring you to pre-medicate with an antibiotic prior to a dental or other invasive procedure?
39. Do you have allergies to makeup?
40. Do you have dry eyes?
41. Do you intentionally tan? Direct Sun / Tanning Bed?
42. Do you have a history of cancer?
43. Do you have a history of stroke or heart attack?
44. To your knowledge, are you allergic or resistant to over-the-counter-level numbing products such as ELA-Max?
45. Do you hypo-pigment (lack of pigment on the skin)?
46. Are you allergic to hair dyes?
47. Do you have arthritis?
48. Do you have low or high blood pressure?
49. Do you have sinus problems?
50. Have you experienced Hepatitis or Jaundice during the past 12 months?
51. Have you had any surgeries in the past 10 years?
52. Please list your ethnic background (Your ethnic background affects the body, skin and it's response to treatment.)
53. How would you describe your skin?
Thanks for submitting!
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