Please enable JavaScript in your browser to complete this form.* indicates a required field Please choose yes or no for each optionHistory of keloid scarring *YesNoCollagen vascular disease (scleroderma, lupus, rheumatoid arthritis, ankylosing spondylitis, Sjogrens, temporal arteritis, psoriatic arthritis, dermatomyositis) *YesNoCardiac abnormalities *YesNoBleeding disorders or haemostatic dysfunction *YesNoUse of blood thinners or anticoagulant medication *YesNoActive infection (cold sores) *YesNoModerate to severe active acne. *YesNoChronic skin disease (eczema, psoriasis) *YesNoCompromised immune system *YesNoConditions that effect wound healing (eg. diabetes, heart disease, immunosupression) *YesNoFiller / botox (within 2 weeks) *YesNoPatient Signature *By Signing above, I acknowledge that I have read all the details in the above consent form and will receive a copy of this form in email after it is signed. Clear Signature Patient Full Name *Date *Patient Email *Patient Phone Number *WebsiteSubmit