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Have you had any current or previous medical problems?

Yes No

Do you have any allergies? (asthma, allergies to certain medications, food, cosmetics, latex, etc)?

Yes No

Do you suffer from an autoimmune disease or one that affects the immune system?

Yes No

Do you suffer from any neurological disease such as myasthenia gravis?

Yes No

History of Chemo/Radiation, Vitiligo, Psoriasis, or any Autoimmune disease?

Yes No

Are you currently under the care of a physician?

Yes No

Are you currently receiving any medical treatment (i.e. aspirin, warfarin, or any other anticoagulant, aminoglycoside antibiotics, etc)?

Yes No

Have you had surgery before, including facial procedures?

Yes No

Do you suffer from epidermal reactions, heretic or infectious type (herpes, acne, etc)?

Yes No

Do you have ANY history of cold sores or shingles? If yes, how frequently, and where do these occur?

Yes No

Do you have any hypersensitivity/allergy to one of the ingredients present in the product (hyaluronic acid, vitamins, lidocaine, botulinum toxin, etc)

Yes No

Do you have any skin conditions, including vitiligo, psoriasis, lupus?

Yes No

Are you pregnant or breastfeeding?

Yes No

Do you smoke?

Yes No

Do you have any scarring problems?

Yes No

Have you used Accutane within the last year?

Yes No

Have you ever taken oral retinoids (Isotretinoin)?

Yes No

Have you had previous botulinum toxin treatment?

Yes No

Did you have any side effects after the injection?

Yes No

Have you had any other treatments within the last week? (Fillers, Botox, Facial Surgery)

Yes No

What are your concerns?

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