Love at First Sight Request Form

Love at First Sight Consultation Form

Private and Confidential
Personal Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Gender*

MaleFemaleOther
Emergency Contact Name

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.
Skin Type Assessment
Fitzpatrick Type

IIIIIIIVVVI
Ethnicity
Last Exposure to UV, Sun or Tanning Bed
PASSIVE TANYNSELF TANNING LOTIONYN
Medical History
Weight
Are you currently taking any medication ?*

YesNoIf yes please list
Current Medication
Have you a Pacemaker or Defibrillator ?*

YNOther
Any Metal Implants?*

YNIf Yes please provide details
Have you any current or history of skin cancer, other cancer pre-malignant moles or suspicious lesions ?*

YNIf yes please provide details
Have you any skin infections (Psoriasis, Eczema) ?*

ynIf Yes please provide details
Have you any Diseases that are stimulated by Heat (Herpes, Simplex) ?*

YNIf Yes please provide details
Have you any skin Disorders or Conditions ( Keloids, Abnormal Wounds Healing, Vitiligo ?*

YNIf so please provide details
Have you any Tattoos or Permanent Makeup ?*

YNIf yes please provide detailsWOULD YOU LIKE TO SPEAK TO OUR TATTOO REMOVAL SPECIALIST ?YesNo thank you
Have you any History of any Bleeding Disorders ?*

YNIf so please give details
Have you any Severe Concurrent medical Conditions ?*

YNIf Yes please provide details
Do you use for medication, Herbs Including Photosensitivity (Accutance, Doxycycline) ?*

YNIf Yes please provide details
Have you had any Laser Resurfacing or Deep Chemical Peeling in the last 3months ?*

YN
Have you any Saphenous, Insufficiency or Severe Varicosity Procedure or Issues*

YNIf Yes please provide details
Have you any Endocrine Disorders or PCOS Issues (Diabetes) ?*

YNIf Yes please provide details
Have you had any Intera-Dermal or Superficial Subdermal Injections, Fillers or Grafts*

YNIf Yes please provide details
Are you pregnant or Nursing ?*

YNIf so Please provide details
Have you an Impaired Immune System ?*

YN
Have you Tanned Skin?*

YN
Are you a Social Drinker ?*

YN
Are you a Social Smoker*

YN
Have you had any Surgical Procedures ?*

YNIf so please provide details
Are you taking any current medications ?*

YNIf so please provide details
List any Allergies
Any Medical Conditions
Give Details
Which service do you require ?*

Morpheus8HydrafacialExosomesInjectablesFillersMesotherapyPlateletMicroneedling with Hyaluronic AcidHair RestorationB12 shotsIV Infusion TheraphyBody contouringLumeccaAttiva
What is the reason you want treatment *
Any Other Considerations
All Information Will Be Kept Completely Private
Consent & Acknowledgement*

I understand that the information on this form is essential to determine my medical and cosmetic needs and provisions for treatment. I understand that if any changes occur in my medical history or health, I will report it to the office as soon as possible. I have read and understand the medical history questionnaire.
Client Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Practitioner Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty:

Love at First Sight Consultation Form

Personal Information

Skin Type Assessment

Medical History

List any Allergies

Any Medical Conditions

Any Other Considerations