Your Name (required)
Date of Birth
Emergency Contact Name
Emergency Contact Phone Number
How did you hear about us?
Do you sun bathe or use tanning beds? YesNo
If so, how often? ---RarelyOnce a monthOnce a weekSeveral times per weekDaily
Are you currently under the care of a physician? YesNo
If yes, please explain
Do you have any of the following medical conditions?
CancerDiabetesHigh blood pressureHerpesArthritisFrequent cold soresHIV/AIDSKeloid scarringSkin disease/Skin lesionsSeizure disorderHepatitisHormone imbalanceThyroid imbalanceBlood clotting abnormalitiesAny active infection
Do you have any other health problems or medical conditions? Please list:
Have you ever had an allergic reaction to any of the following?FoodAnimal ProteinAspirinLidocaineHydrocortisoneHydroquinone or skin bleaching agentsOther
Please describe reaction, if applicable
Please list any oral prescription medications you are presently taking
Are you taking birth control pills? YesNo
What antibiotics do you use to treat infection?
Do you take any medications for heart conditions?
Are you on any mood altering or anti-depression medication?
What topical medications or creams are you currently using?
What herbal supplements do you use regularly?
History (for our female clients)
Are you pregnant or trying to become pregnant? YesNo
Are you breastfeeding? YesNo
Are you using contraception? YesNo
I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor or other health professional of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.