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Family Physician

Please provide the name and address of your family physician.

Please Answer All of the Following Questions:

Female Patients - Are you or could you be pregnant (or nursing)?

Do you experience any excessive bruising/bleeding or have you required special treatment due to bleeding/bruising?

Have you had any reaction to anesthetics (dental/surgery)?

Do You or Any Family Members have the following neurological disorders?

Myasthenia Gravis

Eaton Lambert Syndrom

Do you have Bioaclamide, Dermadive, Dermadeep, Beauticall, Artecoll, Artesense, or any semi-permanent/permanent filler in your face?

If you were previously treated with Botox / Hyaluronic Acid Fillers, please note any complications below:

Please note any other medical conditions, concerns or procedures you have that are not on this form:

Please list any allergies to medications or other substances:

Please list any current medications being taken:

In particular, any non-steroidal anti-inflammatories (Advil, Motrin, ASA) or Coumadin / Plavix.

Please list any current non-prescription medications and/or vitamins you are currently taking:

In particular, Vitamin E or Gingo

How did you get referred to us?

Botox / Fillers Form