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BOOK ONLINE
Li-FT® MEDICAL HEALTH FORM
First Name
Last Name
Address
Phone
Date of birth
Email
Are you pregnant or nursing?
*
Yes
No
Have you had any alcohol in the last 24 hours?
*
Yes
No
Have you ever had cold sores or fever blisters?
*
Yes
No
Do you have any allergies to latex?
*
Yes
No
Have you had a laser or chemical peel within 6 months?
*
Yes
No
Have you ever had any permanent cosmetics or tattoos applied?
*
Yes
No
Do you bruise easily for no obvious reason?
*
Yes
No
Do you routinely use Retin-A, glycolic, or other exfoliating products?
*
Yes
No
Do you wear contact lenses?
*
Yes
No
Are you allergic or sensitive to any metals, for instance metals used for jewelry?
*
Yes
No
Do you have any problems healing?
*
Yes
No
Is your skin oily?
*
Yes
No
Do you use tobacco? If you use tobacco you may heal slower and this affects the timing on scheduling a touchup appointment, if applicable.
*
Yes
No
Do you have any heart conditions?
*
Yes
No
Are you diabetic? If so, Type 1 or Type 2?
*
Yes
No
Do you have any autoimmune disorders?
*
Yes
No
Are you sensitive or allergic to hand creams or body lotions?
*
Yes
No
Do you have your lips injected with filler materials?
*
Yes
No
Do you have botox injections?
*
Yes
No
Do you hyper-pigment? (Tendency to develop dark spots on the skin from wounds or sun)?
*
Yes
No
Do you tend to develop keloid or hypertrophy scars?
*
Yes
No
Do you tend to develop keloid or hypertrophy scars?
*
Yes
No
Do you have any seizure related conditions?
*
Yes
No
Do you tend to faint or become dizzy?
*
Yes
No
Do you bleed excessively from minor cuts?
*
Yes
No
Do you have prosthetic implants?
*
Yes
No
Do you have prosthetic implants?
*
Yes
No
Do you consume aspirin daily?
*
Yes
No
Are you under treatment for depression?
*
Yes
No
Do you have any type of herpes?
*
Yes
No
Are you sensitive to petroleum-based products?
*
Yes
No
If you have permanent cosmetics or tattoos, did you have any problems with healing after they were applied?
*
Yes
No
Are you undergoing radiation or chemo-therapy treatment?
*
Yes
No
Are you now, or have you ever
*
Yes
No
Are you wearing a pacemaker?
*
Yes
No
Do you take prescription drugs?
*
Yes
No
Are you anemic?
*
Yes
No
Do you have a history of skin sensitivities?
*
Yes
No
Do you have any medical condition that has resulted in a medical professional requiring you to pre-medicate with an antibiotic prior to a dental or other invasive procedure?
*
Yes
No
Do you have allergies to makeup?
*
Yes
No
Do you have dry eyes?
*
Yes
No
Do you intentionally tan – Direct sun or tanning bed?
*
Yes
No
Do you personally have any history of cancer?
*
Yes
No
Do you have a history of stroke or heart attack?
*
Yes
No
To your knowledge are you allergic or resistant to over the counter level numbing products such as ELA-Max?
*
Yes
No
Are you allergic to hair dyes?
*
Yes
No
Do you have glaucoma or any other eye disease?
*
Yes
No
Do you have arthritis?
*
Yes
No
Do you have high or low blood pressure?
*
Yes
No
Do you have sinus problems?
*
Yes
No
Have you experienced Hepatitis or Jaundice during the past 12 months?
*
Yes
No
If you answered “Yes” to any questions above, use the this box to provide an explanation.
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