Skin Camouflage Consult Form
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address
City
State / Province
Postal / Zip Code
Contact Number
-
Area Code
Phone Number
Email Address
*
example@example.com
Date of Birth
*
-
Day
-
Month
Year
Date
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
*
Format: (000) 000-0000.
How did you hear about us?
*
Do you have ANY conditions* listed below?
Heart Diseases/Pacemaker
Keloid Scars
High/Low Blood Pressure
Polycystic Ovaries
Hormone Drugs
Anti-inflammatory drugs
Epilepsy
Cold sores/Herpes
Menopause/HRT
Smoking/Quit
Eczema
Pregnant
Hepatitis
Diabetes
Skin Disorders
Thyroid
Psoriasis
Iron Deficiency
Blood Thinner
Prone to Fainting
Liver Disease
Skin Cancer
Hypoglycaemia
Anaemia
Roaccutane (how long?)
Other
Are you currently taking any medication?
*
Yes
No
Medication List
Do you have any allergies?
*
Yes
No
Not Sure
Allergies List
WOMEN: Are you trying to conceive or are you pregnant?
Yes
No
WOMEN: Are you Breastfeeding?
Yes
No
Areas of Concern
*
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