中文版 Client Details Name * First Name Last Name Birthday MM DD YYYY Email Phone (###) ### #### Allergies: ( e.g. Sulphur, aspirin, etc) Have you ever had a reaction or problems with local anaesthetics? Medical History: (incl. cosmetic surgery) Current Medications: (e.g. aspirin, cardiprin, vitamins) Are you on any acne medication? (e.g. Roaccutane) Are you trying to fall pregnant? Are you pregnent or breast feeding? Have you had any previous complications with a treatment or unhappy with the result? Do you have a history of any of the following: (please tick) Arthritis Asthma Autoimmune Disorders Bleeding Discorde Blood Clots/DVT Cancer Cold Sores Contact Lenses Cosmetic Implants Diabetes Eczema Epilepsy Heart Disease Heart Palpitations Hepatitis B or C High Blood Pressure Keloid Scarring Polycystic Ovarian Syrdrome Poor Healing Psoriasis Rheumatic Fover Rosacea Skin Cancer Spinal/Neck Pain Thyroid Disease Vitiligo Wound Infection Other ( please write below ) Thank you!
