Client Demographics and Medical History Form
Email address *
Name *
DOB *
MM
/
DD
/
YYYY
M/F *
Address (street #, name, city, state, zip *
Home Phone
Mobile Phone *
Mobile provider (to receive text reminders) *
Email Address *
Employer
Occupation/Profession
How did you find out about us? *
Please list your primary doctor/dermatologist/plastic surgeon. *
Have you had a skin exam by a dermatologist within the past year?
Doctor's Name (either primary care or dermatologist) *
Sunscreen use *
Approximately how many sunburns have you had in your lifetime?
Are you? *
Stress Level *
Do you have a daily bowel movement? *
Have you had topical anesthetic before? (commonly used when you see the dentist or when you have stitches) *
Do you have any keloid scars? (scars that are raised and puffy) *
Do you have or have you had cancer?
Do you have any of the following health conditions? *
Required
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This form was created inside of Beauty Business Builder.