Client Health History Form

Client Health History Form
Name*

First NameLast Name
Please note: currently accepting female clients only

MaleFemale
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select if any of the following apply to you:

Pregnant or lactatingLaser treatments within last 3 daysRetin A/Retinoids within last 3 daysWaxing/depilatories within last 2 daysCold sores or herpes complexActive infections - fungal, viral or bacterialRashes or wartsSkin cancer or skin cancer treatmentsKeloidsBotox or filler within last 4 weeksHIV/AidsHepatitisDiabetesSensitive skinNone
Any other medical conditions and/or concerns?*
Have you used Accutane within last 12 months?*

YesNo
Current medications/antibiotics?*
Have you had any recent facial treatments, peels or recent surgeries in the last year including ablative dermal procedures? If so, please list them:*
Do you have any known allergies (latex, foods, aspirin, other)?*
I hereby authorize Skin First Ltd. medi spa to take pre-procedural photographs and/or video. I consent to the use of these images for the purposes of pre-procedulral planning and post-procedular evalutaion by the Aestheticians at Skin First Ltd. Medi Spa and I understand that they can be made part of my record. I understand that these photos may be used on social media platforms and displayed on their website. This permission may be rescinded by me at any time to prohibit future use by direct wrtitten commincation with Skin First Ltd. medi spa.
Signature*

Clear
I hereby acknowledge and understand that I am receiving aesthetic treatment(s) at Skin First Ltd. Medi Spa.

I give my voluntary and informed consent to receive any and all the treatment(s). I understand that there may be physical contact involved in these treatments and I am not aware of any medical reasons that would preclude me from requesting or receiving treatments.

I hereby agree to defend, indemnify and save harmless SKIN FIRST medi spa and/or it’s principles, employees, or agents from any claims which might arise in relation to any allergic reaction and/or any other potential liability which might arise from or in the context of the treatments at SKIN FIRST Ltd. medi spa.

I accept any such liability as a voluntary assumption of risk and acknowledge that this is a condition precedent to receiving the treatment(s) requested. I further acknowledge that before and after treatment advice/protocols have been discussed with me; that adherence to such advice/protocols is necessary for optimal treatment results and to avoid undesirable effects after treatment.

I am aware that Laser and Aesthetic treatments can provide both potentional benefits and risks and I am satisfied that all of my questions have been answered. I freely consent to the treatment(s).
Signature*

Clear
Should be Empty: