Client Information & Medical History
In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. all information is strictly confidential.
Emergency Contact Name and Phone
How were you referred to us?
Which of the following best describes your skin type? (Choose one type)
I - Always burns, never tans
II - Always burns, sometimes tans
III - Sometimes burns, always tans
IV - Rarely burns, always tans
V - Brown, moderately pigmented skin
VI - Black Skin
Do you regularly use tanning salons or sun bathe?
If yes, how often?
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This form was created inside of BRIO Med Spa.