Fillers / Botox Checklist
Please answer all the below question
1. Are you currently in good health?
Yes
No
2.Are you currently under a specialist doctor's care?
Yes
No
If so, for what reason?
3.Do you take/use ANY medication, herbal/ natural supplements or topical creams on a regular basis?
Yes
No
4.Do you have ANY allergies to medications, food, latex, or other substances?
Yes
No
Have you had any cold sore breakouts (oral herpes) in the past year?
Yes
No
5.Do you have a history of Keloid Scarring?
Yes
No
6.Do you suffer with Acne, or have you taken medication for Acne in the past 6 months?
Yes
No
7.Do you have ANY current or chronic medical illness, including: Myasthenia Gravis, Amyotrophic Lateral Sclerosis or A any other Neuromuscular disorders?
Yes
No
8.Do you have an autoimmune disease?
Yes
No
If so
9.Have you ever had eyelid or facial surgery?
Yes
No
If so ,When and in which area(s)?
10.Have you previously received BOTOX / DERMAL FILLER injections?
Yes
No
When
Area Treated:
Any Previous Adverse Reaction:
11.For Women:
Are you, or could you be pregnant?
Yes
No
Are you breast feeding??
Yes
No
Patient Signature
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