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MEDICAL HISTORY FORM

Flawless Laser Online Medical History
Currently on Accutane, Epuris, or similar medications? *
Any Allergies? *
Autoimmune disease, HIV, Lupus, Hepatitis? If yes provide diagnosis date, medication dosage and frequency in details field. *
Blood Thinners - Baby Aspirin, Heparin, Coumadin, Warfarin, etc? *
Breast Feeding, pregnancy or planning pregnancy? *
Cancer or post cancer treatments? If yes provide diagnosis date, medication dosage and frequency in details field. *
Cardiovascular problems, Heart ailments? If yes provide diagnosis date, medication dosage and frequency in details field. *
Cold sores or fever blisters without pre-medication? *
Cortisone or steroid injections? *
Dental Work? (recent or pending) *
Diabetes Type 1 or Type 2? If yes provide diagnosis date, medication dosage and frequency and last HBA1C with Date in details field. *
Eczema, psoriasis? *
Currently enlarged or painful glands? *
Epilepsy? If yes provide diagnosis date, medication dosage and frequency in details field. *
Facial waxing services within 7-14 days? *
Hypertension/high blood pressure? If yes provide diagnosis date, medication dosage and frequency in details field. *
Inflammatory conditions? If yes provide diagnosis date, medication dosage and frequency in details field. *
Keloids, pigmented scars, icepick scars, new scar tissue? *
Recent laser procedures, chemical peels, dermabrasion, microdermabrasion? *
Currently on light sensitive medication? *
Lymphatic disorder, inflammation of lymph vessels, lymphedema? If yes provide diagnosis date, medication dosage and frequency in details field. *
Medications (including herb and supplements)? If yes provide dosage & frequency. *
Multiple Sclerosis? If yes provide diagnosis date, medication dosage and frequency in details field. *
Neuromuscular Disorder? If yes provide diagnosis date, medication dosage and frequency in details field. *
Pacemaker or metal implants? *
Phlebitis, varicose veins? *
Pigmented moles, warts or growths, unidentified facial growth or mark? *
Recent accident or serious injury? *
Recent surgical procedure? If yes, describe. *
Rosacea, telangiectasia/couperose? *
Recent Retin-A, Retinol usage? *
Skin abrasions or lesions? *
Seizure disorder? If yes provide diagnosis date, medication dosage and frequency in details field. *
Stage III or IV acne? *
Skin-lightening or bleaching agent? *
Current sunburn? *
Swollen or infected Tonsils? *
Thyroid conditions? If yes provide diagnosis date, medication dosage and frequency in details field. *
Under medical care for an existing or suspected condition or disease? If yes, what? *
Current viral infection, influenza? *
Other contraindications or conditions for the technician to be aware of? *
Previous adverse reaction to Dairy? *
Previous adverse reaction to Aspirin? *
Previous adverse reaction to Hydrocortisone? *
Previous adverse reaction to Lidocaine? *
I acknowledge that I am not pregnant or lactating. *
I acknowledge that I have answered all questions truthfully and completely. *
I acknowledge that Flawless Laser & Body Sculpting has a 24hr cancellation policy. Cancellations with less than 24 hours notice will subject to a fee of $50 per hour for every hour of treatment time that your procedure was scheduled to require. *

CONTACT

Flawless Laser & Body Sculpting

12-1922 9 Ave SE

Calgary, Alberta

PH: 403-264-5200

clientcare@flawlesslaser.ca

HOURS

Mon - Fri       10:00 am - 6:00 pm

Saturday       Closed

Sunday           Closed

Closed on all statutory holidays

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