• Love at First Sight Consultation Form

    Private and Confidential

  • Personal Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Gender*
  • Format: (000) 000-0000.

  • Skin Type Assessment

  • Fitzpatrick Type

  • Medical History

  • Are you currently taking any medication ?*
  • Have you a Pacemaker or Defibrillator ?*
  • Any Metal Implants?*
  • Have you any current or history of skin cancer, other cancer pre-malignant moles or suspicious lesions ?*
  • Have you any skin infections (Psoriasis, Eczema) ?*
  • Have you any Diseases that are stimulated by Heat (Herpes, Simplex) ?*
  • Have you any skin Disorders or Conditions ( Keloids, Abnormal Wounds Healing, Vitiligo ?*
  • Have you any Tattoos or Permanent Makeup ?*
  • Have you any History of any Bleeding Disorders ?*
  • Have you any Severe Concurrent medical Conditions ?*
  • Do you use for medication, Herbs Including Photosensitivity (Accutance, Doxycycline) ?*
  • Have you had any Laser Resurfacing or Deep Chemical Peeling in the last 3months ?*
  • Have you any Saphenous, Insufficiency or Severe Varicosity Procedure or Issues*
  • Have you any Endocrine Disorders or PCOS Issues (Diabetes) ?*
  • Have you had any Intera-Dermal or Superficial Subdermal Injections, Fillers or Grafts*
  • Are you pregnant or Nursing ?*
  • Have you an Impaired Immune System ?*
  • Have you Tanned Skin?*
  • Are you a Social Drinker ?*
  • Are you a Social Smoker*
  • Have you had any Surgical Procedures ?*
  • Are you taking any current medications ?*

  • List any Allergies

  • Any Medical Conditions

  • Which service do you require ?*

  • Any Other Considerations

  • Date*
     - -
  • Date
     - -
  • Should be Empty: