Name *

First Name

Last Name

Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

(###)

###

####

Which of the following describes your skin type? *

Always burns, never tans

Always burns, sometimes tans

Sometimes burns, always tans

Rarely burns, always tans

Brown, moderately pigmented skin

Black skin

Do you have any of the following medical conditions?

Please check all that apply

Cancer

Diabetes

High blood pressure

Herpes

Arthritis

Frequent cold sores

HIV/AIDS

Keloid scarring

Skin disease/Skin lesions

seizure disorder

Hepatitis

Hormone imbalance

Thyroid imbalance

Blood clotting abnormalities

Any active infection

Have you ever had an allergic reaction to any of the following?

Please check all that apply and describe the reaction you experienced

Food

Latex

Aspirin

Lidocaine

Hydrocortisone

Hydroquinone or skin bleaching agents

Others

What oral medications are you presently taking? *

Birth control pills

Hormones

Others

None

Have you ever used accutane? *

if yes, please list when you last used it below

Yes

No

What topical medications or creams are you currently using? *

Retin-A

Others (please list below)

None

Have you ever had laser hair removal? *

Yes

No

Have you used any of the following hair removal methods in the past six weeks?

Shaving

Waxing

Electrolysis

Plucking

Tweezing

Stringing

Depilatories

By checking "Submit and Consent to treatment" I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, estetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. *

Submit and Consent to Treatment