Medical History

Full Name *

Email Address *

Birth Date *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

General Information

1. Are you currently under the care of a Physician? *YesNo

If yes what for?

2. Are you currently under the care of a Dermatologist? *YesNo

If yes what for?

3. Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation? *YesNo

5. Do you have any other health problems or medical conditions?

Medications

7. What oral/topical medications are you presently taking?Birth Control pillsHormonesOthers

8. Are you on any mood altering or anti-depression medication? *YesNo

9. Have you ever used Accutane? *YesNo

If yes, when did you last use it?

History

10. Do you take herbal supplements *YesNo

11. Have you ever had laser hair removal? *YesNo

12. Have you had any recent tanning or sun exposure? *YesNo

13. Do you form thick or raised scars from cuts or burns? *YesNo

14. Do you have Hyperpigmentation (darkening of the skin), or Hypopigmentation (lightening of the skin or marks) after physical trauma? *YesNo

If yes, please explain:

15. Have you ever had local anesthesia with lidocaine? *YesNo

Female Clients

16. Are you pregnant or trying to become pregnant?YesNo

17. Are you breastfeeding?YesNo

18. Are you using contraception?YesNo

Which of the following best describes your skin type? *1. Always burn, never tan2. Always burn, sometimes tan3. Sometimes burn, always tan4. Rarely bum, always tan5. Brown, moderately pigmented skin6. Heavily pigmented skin, very dark hair

Please indicate the services and areas of interest

Laser Hair Removal

Area of Interest

Hair Color

Current Method of Hair Removal

Skin Rejuvenation

Area of Interest

Cellulite Reduction/Body Contouring/Circumferential Reduction

Med Spa Location

Find Us And Say Hi

Thank you