Consultation Form
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Name *
Date of Birth *
MM
/
DD
/
YYYY
Occupation
Full Address (Street/City/State/Zip) *
Phone Number *
Emergency Contact (Name & Number) *
How were you referred to us? (if Friend, please list their name) *
Which of the following describes your skin type? *
Do you regularly use tanning salons, or sunbathe? *
Have you ever used Acutane? *
If yes, to using Acutane, when was the last time you used it?
Are you currently under the care of a physician? *
If yes, please explain why
Do you have any of the following medical conditions?  Please check all that apply *
Required
Please list any other medical conditions
Have you ever had an allergic reaction to any of the following?  Please check all that apply. *
Required
If you marked yes to any allergic reactions, pleaes describe the reaction here.
What oral medications are currently taking? *
Required
If you chose other, please list:
Are you on mood altering, or anti-depressant medication? *
Are you using any products with Retin-A? *
What topical medications or creams are you using? *
What herbal supplements do you take regulary? *
Have you used any of the following hair removal techniques in the past 6 weeks?  Check all that apply *
Required
Have you had any recent tanning or sun exposure that changed the color of your skin? *
Have you recently used any self-tanning lotions or treatments? *
Do you form thick or raised scars from cuts or burns? *
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? *
If yes, please describe:
Are you pregnant, or trying to get pregnant? *
Are you currently breastfeeding? *
Please describe what you would like to discuss at your consultation. *
I certify that the preceding medical, personal, and skin history are true and correct. I am aware that is it my responsibility to inform the technician, esthetician, therapist, doctor or nurse 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. I agree to electronically sign this document by entering my name and date (MM/DD/YYYY), and understand this is in place of a handwritten signature *
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