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Profhilo Consent Form

Please fill out the following form
in order to participate in our activity.

Are you currently in good health?
cardiac pacemakers, implanted defibrillators, implanted neurostimulators
drug pumps
Do you carry a warning card, an EpiPen, or have you ever had an anaphylaxis reaction?
malignant tumor
sensitivity or allergy to latex
haemorrhagic conditions
anticoagulation therapy
heart disorders
Are you currently under a specialist, hospital or doctor’s care
areas of the skin which lack normal sensation
Do you use ANY medication, herbal/natural supplements or topical creams on a regular basis
Do you have ANY allergies to medications, food, latex, or other substances
Have you had any cold sore breakouts (oral herpes) in the past year
Do you have a history of Keloid Scarring
Any blood-borne diseases
A stroke or any other blood pressure problems
Any neurological conditions such as epilepsy, Bell’s Palsy, MS, Chorea or Myasthenia Gravis
Allergic to latex, antibiotics, foods, drugs/substances
Any recent vaccinations, cortisone injections or steroids
Replacements, implants, operations, X-rays recently
Do you suffer with Acne, or have you taken medication for Acne in the past 6 months
Do you have ANY current or chronic medical illness, including: Myasthenia Gravis, Amyotrophic Lateral Sclerosis or any other Neuromuscular disorders
Do you have an autoimmune disease
Jaundice, Hepatitis, Liver or Kidney disease
Have you ever had eyelid or facial surgery
Asthma, Eczema or other allergic disease
Deep skin peeling
Have you previously received BOTOX/ DERMAL FILLER injections
Are you, or could you be pregnant
Are you going through IVF
Are you breastfeeding
Taking medicines, pills, tablets, ointments or inhalers
Use therapies or supplements such as St. John’s Wort?
Do you bruise or bleed easily
Any circulative problems or varicose veins
Any auto-immune disease, including lupus
Any endocrine disorders? (diabetes, thyroid)
Do you follow a healthy diet?

Thanks for submitting!

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