Clinic Record

Are you presently under a physician’s care for any current condition or other problem?*

YesNo

Which?

Are you presently using (or used in the past) Botox, Fillers, PDO threads or another injectable products?*

YesNo

When and for how long?

Are you now using, or have you ever used any medicine cream or moisture?*

YesNo

Which?

Do you have any important antecedents of Cancer or important diseases in your Family?*

YesNo

Who?

Are you presently taking any medications?*

YesNo

Please List

Have you had or has cancer?*

YesNo

Where?

Do you often experience stress?*

YesNo

Do you smoke?*

YesNo

Allergies?*

YesNo

Please list any allergies or Anesthesia reactions:

Did you used Laser procedures, Ultrasound, Hifu or another technology machines?*

YesNo

Which?

Please check if you have any medical conditions or if you are affected by or have any of the following:*

If affected, please explain or list any other significant issues we should know about:

Name*

Date Signed*

Signature*

By signature below, I hereby authorize to Caras Facial Center members, Doctors, Esthetician or Health providers to Administer treatment or procedure on bodywork or facial to my child or dependent as they deem necessary.

Signature*

Date Signed*

CLINIC RECORD

For Women’s

Consent to Treatment of Minor