Step 1 of 2 50% Client InformationName* First Last Date Of Birth* Month Day Year Phone*Emergency ContactAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Treatment Area* Upload Your IdMax. file size: 30 MB. Some medical conditions may be contraindication to receiving the procedure, so it is important you provide the information below. It is ultimately your responsibility to ensure that you understand in full the Fibroblast procedure and the expected outcomes before your treatment commences.Please select any of the following contraindications that pertain to you.*NoneCold Sores/Herpes/ShinglesBotox/Fillers within past 21 daysCosmetic Surgery in past yearPregnant/Breast FeedingCancerIf you Selected any of the above, please explain :I understand post-treatment I may not look my best for the next few days and may potentially experience some minor discomfort, redness and swelling* YES NO Do you have any allergies or have you ever experienced allergic reactions to any kinds of medications, foods or products* YES NO Do you or have you ever suffered an allergic reaction to any local/topical anesthetics* YES NO Are you currently undergoing any medical treatment and/or have you received any medical treatment within the last 6 months* YES NO Are you currently taking any medication This includes any over the counter remedies.* YES NO Do you knowingly have an infectious disease or other acute or chronic disease* YES NO Do you suffer from uncontrolled, high or low blood pressure or any other kind of circulatory issues or defi ciencies* YES NO Do you suffer from dizziness, fainting attacks or any other seizure related condition?* YES NO Do you have any history of cancer? If yes, have you had any radiation or chemotherapy treatment* YES NO Do you currently have or have you ever been treated for any pigmentation disorders such as Melasma, Age Spots, Hyperpigmentation, Vitiligo and Solar Lentigines etc.* YES NO Do you ever develop dark spots on the skin from wounds* YES NO Are you taking or have you applied any oral/topical steroids or corticosteroids in the last 6 months? This would include Hydrocortisone for Eczema.* YES NO Do you suffer from, or have any problems with scars healing? Do you suffer from keloid scarring, hypertrophic scarring or any other type of scarring* YES NO Do you regularly use Retinol, Glycol, Salicylic Acid or benzoyl peroxide or any other exfoliating products devices (Clarisonic)* YES NO Have you ever had any recent Permanent Make Up (PMU) or cosmetic treatment If so when and did you experience any problems healing* YES NO Do you have any corneal abrasion or retinal detachment* YES NO Do you have any prosthetic implants or any plates or pins in the area being treated by Fibroblast* YES NO Is there any other ailment or reason not listed you feel we should know about which could prevent us from delivering your treatment?* YES NO Explain :Please initial each paragraph after reading :* I acknowledge that this is an elective procedure at my request. I certify that I have listed all medications/medical procedures/ medical disorders. Fibroblasting cannot guarantee the exact outcome of this procedure and results may vary from client to client. I grant consent to photographs being taken BEFORE, DURING and AFTER my Fibroblast procedure. I certify I have received written post treatment instructions I agree to follow all aftercare instructions to reduce the risk of post-procedural infection, hyperpigmentation and potential scarring. Date* MM slash DD slash YYYY
