Client Information & Medical History

Your Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Address*

Home Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Format: (000) 000-0000.
Email*
Emergency Contact Name
Emergency Contact Phone
Format: (000) 000-0000.
How did you hear about us?
Medical History
Are you currently under the care of a physician?*

YesNo
If yes, for what?*
Are you currently under the care of a dermatologist?*

YesNo
If yes, for what?*
Do you have any of the following medical conditions? (select all that apply)

ArthritisBlood clotting abnormalities / bruise easilyCancerDiabetesEczemaFrequent cold soresHepatitisHerpesHigh blood pressureHIV / AIDSHivesHormone imbalanceKeloid scarringLupusPsoriasisRosaceaSeizure disorderSkin disease / skin lesionsThyroid imbalanceAny active infectionOther
Have you ever had an allergic reaction to any of the following? (select all that apply)

FoodLatexLidocaineHydrocortisoneAspirinHydroquinone or skin bleaching agentsOther
Do you wear contact lenses? If so, please remove them on the day of your treatment.*

YesNo
Have you had surgery in the treatment area in the last 3 months?*

YesNo
Do you smoke cigarettes, use Marijuana or vape? This can affect how you heal from your treatments.*

YesNo
Medications
Are you taking any of the following oral medications? (select all that apply)

Birth control pillsHormonesOther
Have you ever used Accutane?*

YesNo
If yes, when did you last use it?*
Have you taken oral antibiotics in the last month?*

YesNo
If yes, what and when did you stop?*
Are you currently taking any vitamins, supplements or herbal remedies?*

YesNo
If yes, please list below.*
Skin Type / Skincare History
Which of the following best describes your skin type (please select only one)?*

Always burns, never tansAlways burns, sometimes tansSometimes burns, always tansRarely burns, always tansBrown moderately pigmented skinBlack skin
Do you regularly use tanning salons or sun bathe?*

YesNo
If yes, how often?*
Have you had any recent tanning or sun exposure that changed the color of your skin?*

YesNo
Have you recently used any self-tanning lotions or treatments?*

YesNo
Do you form thick or raised scars from cuts or burns?*

YesNo
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*

YesNo
If yes, please describe:*
Have you used any of the following hair removal methods in the past six weeks? (select all that apply)

ElectrolysisTweezingShavingWaxingPluckingStringingOther
Please list below all of the skincare products that you are currently using.*
Do you have any metal in your body?*

YesNo
If yes, please describe what and where.*
Have you had Botox or filler in the last month?*

YesNo
If yes, please describe what and where.*
Are you currently using Retinol, Retin A, Tretinoin or products that contain alpha or beta hydroxy acids?*

YesNo
If yes, please describe what and when you last used the product.*
For Our Female Clients
Are you pregnant or trying to become pregnant?

YesNo
Are you breastfeeding?

YesNo
Are you using contraception?

YesNo
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, esthetician, 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.
Today's Date*

MonthDayYear
Date
Your Signature*
Should be Empty:

Medical History

Medications

Skin Type / Skincare History

For Our Female Clients