Peachy Laser Lounge
Intake Form
Patient Information
Date:
*
-
Month
-
Day
Year
Date
Name:
*
First Name
Last Name
Gender:
*
Please Select
Male
Female
X
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
*
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
*
example@example.com
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Medical History
Do you have any of the following? Please check which apply to you:
Cancer
Skin Cancer
Diabetes
High Blood Pressure
Herpes
Frequent Cold Sores
HIV/AIDS
Keloid Scarring
Skin Disease
Seizure Disorder
Hepatitis
Hormone Imbalance
Thyroid
Blood Clotting
Rosacea
Psoriasis
Hyperpigmentation
Eczema
Cardiac Pacemaker or Defibrillator
Benign or Malignant Tumors
Metal Implants
If you have any Metal Implants, please specify where:
Are you pregnant or breastfeeding?
*
Please Select
Pregnant
Breastfeeding
Neither
Please list any other medical conditions or allergies:
Please list any medications you are currently taking including vitamins:
Please list any surgeries you have had and when:
Do you use sunscreen?
*
Yes
No
If yes, please specify SPF #:
Signature
*
Submit
Submit
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