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Head
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What condition(s)/skin concern(s) do you have?
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Unwanted/Ingrown Hair
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Uneven Skin Tone
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Do you have ANY current or chronic medical illnesses? If yes, please list:
Disclose any history of heat urticaria, diabetes, autoimmune disorders or any immunosuppression, blood disorders, cancer, bacterial or viral infections, medical conditions that significantly compromise the healing response, skin photosensitivity disorders, or any other condition or illness.
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Do you have ANY current or chronic skin conditions?
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Disclose any history of vitiligo, eczema, melasma, psoriasis, allergic dermatitis, any diseases affecting collagen including Ehlers-Danlos syndrome, scleroderma, skin cancer, or any other skin condition.
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Are you currently under a doctor’s care? If so, for what reason?
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Reason
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Do you take/use ANY medications (prescriptions and non-prescriptions), vitamins, herbal or natural supplements, on a regular or daily basis? If Yes, please list:
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Are there any topical products (both medical and non-medical) that you use on your skin on a daily basis?
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Do you take/use ANY systemic/oral steroids (e.g., prednisone, dexamethasone)?
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Do you have ANY allergies to medications, foods, latex or other substances
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(For women) are you or could you be pregnant?
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(For women) are menstrual periods regular, or have you ever been diagnosed with Polycystic Ovarian Disorder?
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Yes
No
Do you have a history of herpes I or II (cold sores) in the area to be treated?
Yes
No
Do you have a history of keloid scarring or hypertropic scar formation?
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Yes
No
Do you have a history of light induced seizures?
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Do you have any open sores or lesions?
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Do you have any history of radiation therapy in the area to be treated?
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Yes
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In the last six (6) months, have you used any of the following: anticoagulants or blood-thinning medications; photosensitizing medications (e.g. Erythromycin, use of perfume in area/s you want to be treated); or anti-inflammatory or blood thinning medications?
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Yes
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Please list product name and date last used:
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In the last three (3) months, have you used any of the following products: glycolic acid or other alpha hydroxy or betahydroxy acid products; exfoliating or resurfacing products or treatments?
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Yes
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Please list product name and date last used:
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Do you have or have you ever had any permanent make-up, tattoos, implants, or fillers, including, but not limited to, collagen, autololgous fat, Hyaluronic acid fillers such as Juvederm®, Restylane®, etc.?
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Yes
No
If yes, please list locations on or in the body and dates:
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Do you have or have you ever had any Botulinum toxin injections, such as Botox® or Dysport®?
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If yes, please list locations on or in the body and dates:
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Have you taken Accutane® (or products containing isotretinoin) in the last 12 months?
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Have you taken Tretinoin (like Retin-A®, Renova®) in the last 6 months?
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Have you had any unprotected sun exposure, used tanning creams (including sunless tanning lotions) or tanning beds or lamps in the last 4-6 weeks?
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Declaration
BY CHECKING THIS CHECKBOX, I HEREBY DECLARE THAT THE DETAILS FURNISHED ABOVE ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF AND I UNDERTAKE TO INFORM YOU OF ANY CHANGES THEREIN, IMMEDIATELY. IN CASE OF ANY OF THE ABOVE INFORMATION IS FOUND FALSE OR UNTRUE OR MISLEADING OR MISREPRESENTING. I AM AWARE THAT IT CAN AFFECT THE TREATMENT, PRODUCTS AND/OR MEDICATIONS THAT I WILL UNDERGO FROM FOURWAYS AESTHETIC CENTRE.
Yes, I agree.
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