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Skinpharma Medical Questionnaire

Please complete all parts of the questionnaire. Contact us, if you'd like to ask any questions.

Click the SUBMIT button to send us your information securely.

Medical Questionnaire

Have you had any previous medical problems? If so, please add these to the notes (below)
Have you had surgery before? If so, please add these to the notes (below)
Are you currently receiving any medical treatment? (i.e. aspirin, warfarin, or any other anticoagulant, aminoglycoside antibiotics, etc...)? If so, please add these to the notes (below)
Are you pregnant or breastfeeding?
Do you smoke cigarettes/tobacco?
Do you have any scarring problems?
Do you have any allergies? (asthma, allergies to certain medications, food, cosmetics, latex, etc...)? If so, please add these to the notes (below)
Do you have any hypersensitivity/allergy to one of the ingredients present in the product (hyaluronic acid, vitamins, lidocaine, botulinum toxin, etc...)?
Do you suffer from skin infection?
Do you suffer from an autoimmune disease or one that affects the immune system?
Do you suffer from any neurological disease (nerve problem) such as myasthenia gravis?
Do you suffer from any urinary/bladder disease or infection?
Do you suffer from a disease affecting the thyroid gland?
Do you suffer from hepatocellular insufficiency (liver problems)?
Do you often suffer from angina or rheumatism on a regular basis?
Do you suffer from epilepsy?
Do you suffer from any skin conditions or infections (shingles, acne, etc...)? If so, please add these to the notes (below)
Have you had any botulinum toxin (e.g. Botox) aesthetic treatments previously? If so, please add these treatments to the notes (below) & mention any side-effects you may have had with the treatment
Have you had any dermal filler (e.g. Juvederm) aesthetic treatments previously? If so, please add these treatments to the notes (below) & mention any side-effects you may have had with the treatment
Please upload FRONT photo here

Thanks for submitting!

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