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Brazilian Butt Lift (BBL) Miami
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Medical History Form
All Questions Require An Answer - Please Write "N/A" If Not Applicable
Do You Have Any Drug Allergies? If So Please List:
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Do You Take Any Medications, Supplements, Vitamins, Or Birth Control (Including IUD & Patches)? If So Please List:
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Do You Currently Have Any Medical Conditions Or Have You Had Any In The Past? (Ex: Anemia, Asthma, Hyperthyroid, Hypertension, Diabetes, Cancer, Hepatitis, HIV, Etc. ) If so please list:
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Any Family History Of Cancer? If so What Type & What Family Member?:
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Have You Ever Been Hospitalized? If so for What & When ?:
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Do you have any history of DVT or Pulmonary embolism? :
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Please List All Medical, Surgical, & Cosmetic Procedures You Have Ever Had
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Please List All Pregnancies, Miscarriages, And Abortions With Date ( Please Note Procedures Must Be 1 Year Post Full Term Pregnancy & 8 Weeks Post Abortions:
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Do You Consume Alcohol? If So How Often?
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Do You Use Any Type of Recreational Drugs? If So Please List Which, How Often & When was the last date of use?
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Do You Smoke, Chew, or are Exposed to Second Hand Smoke of any Form Of Nicotine?
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Do You have Sickle Cell Disease or Sickle Cell Trait? (If so please state which one):
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Do you have any children?
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