Medical History Form
LavishN’ Curves
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Ok to Text?
*
Please Select
Yes
NO
Email
*
example@example.com
Date Of Birth 00/00/00
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sex
*
Please Select
Female
Male
Non-binary
Doctor Name & Facility Location
*
Emergency Contact
*
First Name
Last Name
Emergency Contact's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship?
*
How Did you find out about us?
Which body area(s) or conditions would you like treated? Please mark N/A if no.
*
Please answer each of the following questions:
Do you have ANY allergies to medications, foods, latex, or other substances? Please list:
*
Do you Smoke?
*
Please Select
Yes
No
Average per day? If not please mark N/A
*
Do you drink alcohol?
*
Please Select
Yes
No
Average per day? If not please mark N/A
*
Do you have ANY current or chronic medical conditions?Disclose any history of heat urticaria, diabetes, autoimmune disorder or any immunosuppression, blood disorders, cancer, bacterial or viral infections, medical conditions that significantly compromise the healing response, skin photosensitivity disorders, or any other condition or illness.
*
Please Select
Yes
No
If Yes, Please list, Please mark N/A if no..
*
Do you have ANY current or chronic skin conditions? Also disclose any history of vitiligo, eczema, melasma, psoriasis, allergic dermatitis, any diseases affecting collagen including Ehlers-Danlos syndrome, scleroderma, skin cancer, or any other skin condition.
*
Please Select
Yes
No
If Yes, Please list, Please mark N/A if no..
*
Are you under a doctor’s care?
*
Please Select
Yes
No
If so, which location? Please mark N/A if no..
*
Do you take ANY medications (prescriptions or non-prescriptions) including vitamins and herbal supplements on a regular basis?
*
Please Select
Yes
No
If so, for what? Please mark N/A if no..
*
Do you have any metal devices in your body?
*
Please Select
Yes
No
If so, for what? Please mark N/A if no.
*
Have you had any cosmetic procedures in the past 6 months?
*
Please Select
Yes
No
If so, when was the surgery date & procedure? Please mark N/A if no.
*
Have you had any Post-op Lymphatic Massage, Skin Tightening Wood Therapy, Cellulite Treatment: including but not limited to Ultrasound Cavitation, Radio Frequency ect.?
*
Please Select
Yes
No
If yes, please list dates, Please mark N/A if no.
*
For Women Only
Are you pregnant or breastfeeding?
*
Please Select
Yes
No
N/A
Are your menstrual periods regular
*
Please Select
Yes
No
N/A
Have you been diagnosed with Polycystic ovary syndrome?
*
Please Select
Yes
No
N/A
Name
*
First Name
Last Name
Signature
*
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