Oasis Laser Skin Clinic - Medical History Form

Medical History Form for DermaRoller/ eDermaStamp Treatments
Personal Information:
Name:*
Date of Birth:*

MonthDayYear
Address: *
Occupation: *
Tel./Cell:*
Format: (000) 000-0000.
E-mail Address :*
Health Questionnaire:
Existing or recent illness:*
Hospitalization / surgery:*
Medication*
Medicine intolerance: *
Aesthetic procedures in thetreatment area within the last 6months:*
Allergies (including to cosmeticproducts)*
Under 18 years of age.Pregnancy or nursingCurrent or history of cancer, especially skin cancer, or pre-malignant moles.Any active condition in the treatment area such as sores, active pustular acne, rosacea,keloid or raised scars, septic conditions, psoriasis, eczema and rash as well as irritatedor damaged skin due to excessive fresh tanning.Any active bacterial, viral or fungal infectionsVascular disorders such as: un-controlled diabetes, nervous diseases, cardiac disorderand cancer. In such cases, consult the treating physician.Any recent use of products such as Accutane or Retin A.Taking blood pressure, blood thinning or heart medications.Actinic (solar) keratosis - Immunosuppression
I, the undersigned pledge to inform of all changes in my physical condition.
I confirm that I do not suffer from any of the above described conditions.
I declared that the above information is true and correct.
Customer’s Name *
Signature*

Clear
Date*

MonthDayYear
Practitioner’s Name:*
Signature:*

Clear
Should be Empty: