ONLINE MEDICAL FORM

PLEASE ANSWER YES OR NO TO ALL OF THE FOLLOWING QUESTIONS:
Do you have ANY current medical illnesses we should know about? If so, please explain:
Are you currently under a doctors care? If so, for what reason:
Do you take ANY medications, vitamins or herbs, topically or orally? Please list:
Do you have or have you ever had ANY allergies to medications, food, latex or other substances? If so, please list:
WOMEN ONLY: Is it possible that you could be pregnant or breast feeding?
WOMEN ONLY: Are you close to or on your menstrual cycle?
Do you have a history or herpes/coldsores in the are to be treated?
Do you have a history of keloid, hypertrophic or pigment scarring?
Have you used accutane (roaccutane) or RetinA topically or orally? If so, when:
Do you have any permanent make-up or tattoos in the areas to be treated? If so, please list:
Do you have any medical or cosmetic implants? If so, please list:
Have you had any cosmetic injectables? If so, what & when:
Have you had any exposure to the sun in the past 6 weeks?
Have you used fake tan or tanning moisturiser in the last 6 weeks?
What areas of the face & body were you looking at treating?
What treatments or products are you interested in?
What is your mothers nationality?
What is your fathers nationality?
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