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Please check if you have or have had
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If yes, please explain:
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Under the care of a physician?
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Present Medications/Dosages
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History of Autoimmune Disease?
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History of HSV1 or HSV2
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Topical Medications you are currently using
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Allergies:
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Recent sun or tan exposure:
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Date of last tan exposure
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implants/injectables or permanent make-up
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if yes, please explain areas
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Cosmetic Peel/Cosmetic Procedure
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If yes, please explain:
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Tattoos:
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History of keloids/hypertrophic scars
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Females Only
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Are you Pregnant?
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Are you Breastfeeding?
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Discussion with Patient
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I consent the following is true and correct
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Notes:
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Signature of Patient
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Signature of NP/PA
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Signature of Medical Director
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