• Medical/Intake Questionnaire

    Medical/Intake Questionnaire

  • Format: (000) 000-0000.
  • Do you understand that you must avoid Botox in the procedure area 2 weeks prior to your scheduled session?*
  • Do you have any complications with healing? Diabetes, Eczema, Psoriasis, Sunburn, Keloids or Hypertrophic scarring in the procedure area?*
  • Are you pregnant or currently breast feeding?*
  • Have you used Accutane in the last 12 months?*
  • Are you currently undergoing Chemotherapy?*
  • Have you had any surgery in the past 30 days?*
  • Other medical history you would like to share?
  • Are you currently prescribed or taking any blood thinning medications the day of your procedure including ibuprofen and/or fish oil?*
  • Are you able to sit and/or lay on your back for at least 2 hours?*
  • Can you avoid alcohol and/or caffeine 24 hours prior to your procedure?*
  • Are you able to follow aftercare instructions provided?*
  • Should be Empty: