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  • MEDICAL HISTORY

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  • There exists a risk if our staff is not aware of the general health and medical background of a client. This information may critically affect what procedure we may recommend or safely undertake. Please provide us with the following information and keep it updated.

  • Please check all of the following medical conditions you now have or have had in the past. If you have had none, please check “none of the above”.*
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  • Are you a smoker?*
  • Is there any possibility that you may be pregnant at this time?*
  • Do you have a history of cold sores?*
  • Do you or your family have a history of atypical moles, vitiligo, developing keloids, melanoma, or skin cancer?*
  • Have you or anyone in your family ever had, or currently have, a history of unusual reactions or problems with LOCAL anesthesia (e.g. dental freezing), TOPICAL anesthesia (e.g. anesthetic creams or gels) resulting in rashes, muscle weakness, jaundice, breathingproblems, and/or unexpected fever(s)?*

  • I acknowledge that I have disclosed my complete medical history and the above is a complete and accurate representation of my medical and psychological status.

  • I         represent to the physicians and staff that I am at least 18 (eighteen) years of age or, if not, am accompanied by a legal guardian. I hereby consent to and authorize a history examination by my doctor and such assistant or staff as may be assigned by him/her.
    If appropriate, I authorize the release of any medical information for the purpose of processing insurance claims on my behalf. I authorize payments of medical benefits directly to the doctor for services provided to me. A copy of this authorization shall be considered as valid as the original. I understand that photography is a necessary part of planning and evaluating cosmetic procedures. I authorize the taking of photographs at the direction of my physician or physician delegate and under such conditions as may be approved by him/her. These photographs will be used solely for documentation purposes and will be kept confidential unless otherwise disclosed.
    I understand that there is a consultation fee for the initial visit, which is due at the time of my appointment unless other arrangements have been made in advance.

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  • RELATIONSHIP:*
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