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Health & Medical History
Please check any of the following that apply*
*
Contagious Skin Disorders
Cancer, Chemo or Radiation
Diabetes
Cardiac Disease
Pacemaker or Internal Defibrillator
Laser or IPL within last 7 days
Roaccutane or other prescription medicine
Photosensitizing Medication
Blood thiners/Asprin
Metal plates/pins
High/Low Blood Pressure
Pregnancy/Breastfeeding
Vascular Conditions
Varicose Veins
Metabolic Conditions
Hypertriglceridemia
Hearing aids - will need to be turned off and removed
Liver disease or high cholesterol
Autoimmune disease or poor lymphatic System
Cold sores
Skin irritation, rash, open lesions
None of the above
count
If you checked yes to any of these please provide further information.
Name
First Name
Last Name
Phone Number
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Format: (000) 000-0000.
Email
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