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Client Medical History
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What procedures are you interested in? Check all that apply.
Procedures interest in
Laser hair removal
Facial
Skin Tightening
Tatoo Removal
Botox/Dysport
Dermal Fillers
PRP
Teeth whitening
What would you like to acheive from your treatments?
List all medications and supplements:
Please check any conditions that you currently have or have had in the past.
Heart Problems
Auto Immune Disease
Exzema
Pacemaker
Anxiety
Excessive Hair Growth
Diabetes
Bruise Easily
Psoriasis
Metal Implant
Depression
Excessive Hair Loss
HIV
Poor Wound Healing
Vitiligo
Seizure
Hyper Thyroid
Permanent Makeup
Lupus
Asthma
Keloid Scarring
Epilepsy
PCOS
Tattoo
MS
ALS
Bell's Palsy
Cold Sores
Shingles
High Blood Preasure
Varicose Veins
Have you ever had a facial treatment before?
Yes
No
Which of the following best describes your skin when exposed to the sun for 30 minutes & no SPF?
Always burns easily, never tans with very pale skin tone
Always burns tans with a hint of color
Burns initially tans gradually
Can burn and can tan
Rarely burns
Your ethnicity?
* Required field
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