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Physician Laser Centers
Medical History
*Print, fill out and bring with you to your appointment
Pacemaker/Defibrillator |
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Active skin infection (e.g. psoriasis, eczema) |
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Metal Implants |
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Skin Disorders (e.g. keloids, abnormal wound healing) |
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Current or History of skin cancer/other cancer/ pre-malignant moles |
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History of bleeding disorders |
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Severe or concurrent medical conditions (e.g. cardiac disorders) |
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Use of medication/herbs inducing photosensitivity |
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Pregnancy and nursing |
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Facial Laser resurfacing/deep chemical peeling, within the last 3 months |
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Impaired immune system |
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Needle epilation, waxing or tweezing, within the last 6 months |
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Diseases stimulated by light (e.g. Lupus, Porphyria, Epilepsy) |
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Tattoo or Permanent Makeup |
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Diseases stimulated by heat (e.g. Herpes Simplex) |
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Tanned Skin (e.g. do you tan regularly) |
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Endocrine disorders (e.g. Diabetes, PCO) |
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Sapheneous Insufficiency |
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Medications |
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Allergies |
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Detail any medical condition |
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Other considerations |
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