Your name Your email Do you have a keloid ? or history of sensitive skin? YesNo Are you taking any anti-inflammatory medication or steroids? ---YesNo Do you Wear contacts? YesNo Are you Pregnant or nursing? YesNo Are you allergic to any metals? YesNo Are you undergoing radiation or Chemotherapy ? Must Wait until AFTER Chemotherapy and Clearance from doctor to accept. YesNo Have you had any aspirin or blood thinning products with-in the last 7 days? YesNo Please Select All that Applies? Do you have any of the following that may pertain to you: Heart Conditionsallergies to makeupdry eyesshortness of breathkeloid or hypertrophy scarskeloid formationrefractive eye surgeryalopeciadiabetesAutoimmune disordersTrichotillmaniaHepatitis/Jaundice HIVKidney DiseaseTendency to develop feverchest painsGlaucomaCancer ( Any Type)StrokeEpilepsy/ seizuresOcular HerpesNone Please include doctors name and Phone number If have any conditions listed above: Your answer Please Explain any checked questions and list any other medical conditions and all medications being taken currently. Your answer Are you currently using Retin-A or Alpha Hydroxy skin care products? YesNo
