Client Medical History + Skin Profile

Today's Date*

Date

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Birthdate*

Age*

Sex*

Emergency Contact Name*

Relationship*

Emergency Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Doctor's Name*

Doctor's Phone Number*

Preferred Pharmacy*

Pharmacy Phone Number*

Have you been treated anywhere in the past for aesthetic purposes?*

Are you CURRENTLY being treated anywhere for aesthetic purposes and treatments? This important information for us to make sure there are no interactions with treatments you are doing elsewhere.*

Do any of the following medical conditions apply to you? (Check all that apply or any past diagnosis. Choose NONE if none apply)*

Please describe in more detail on any medical conditions checked above such as date of occurrence area of body, current treatment, past conditions etc.*

Explain any other current medical conditions.*

List any current medications and supplements and their purpose.*

Are you allergic to any foods, medications or topical ingredients?*

Are you presently under a physician's care? If so, for what?*

I REPRESENT THAT MY MEDICAL HISTORY IS COMPLETE AND I UNDERSTAND THAT I MAY NOT BE ABLE TO RECEIVE TREATMENT DUE TO A MEDICAL CONDITION.

Name*

First NameLast Name

Signature*

Date*

Date

Client Medical History

Client Skin Profile