Please fill out the following form to ensure that services are properly prepared for. Failure to disclose accurate information could result in a termination of services. All client information is private and secured in accordance with the HIPPA act.

First Name

Last Name

Age

Phone Number

Email

Address

City

State

Zipcode

Occupation

Are you pregnant or nursing?

Yes

No

Have you had any alcohol in the last 24 hours?

Yes

No

Have you ever had cold sores or fever blisters?

Yes

No

Do you have a latex allergy?

Yes

No

Have you had a laser service or chemical peel in the last 6 months?

Yes

No

Have you ever had any permanent cosmetics or tattoos applied?

Yes

No

Do you bruise easily for no obvious reason?

Yes

No

Do you routinely use Retin-A or any skincare products containing chemical exfoliators? (i.e salicylic acid, glycolic acid, AHA, BHA, lactic acid)

Yes

No

Do you wear contact lenses?

Yes

No

Are you allergic/sensitive to any metals? (i.e jewelry)

Yes

No

Do you have any problems healing from small wounds?

Yes

No

Is your skin oily?

Yes

No

Do you use tobacco? Tobacco use may cause slower healing and faster fading.

Yes

No

Are you diabetic?

Type 1

Type 2

No

Do you have any autoimmune disorders?

Yes

No

Do you have a history of skin sensitivity?

Yes

No

Do you have allergies to makeup?

Yes

No

Are you sensitive or allergic to body lotions?

Yes

No

Are you allergic to hair dye?

Yes

No

Are you sensitive to petroleum-based products?

Yes

No

Do you have lip filler?

Yes

No

Do you get botox injections?

Yes

No

Do you hyperpigment? (develop dark spots from wounds or sun)

Yes

No

Do you hypopigment? (develop light spots from wounds)

Yes

No

Do you tend to develop keloid (purple, very raised) or hypertrophic (slightly raised) scars?

Yes

No

Do you scar easily from minor injuries?

Yes

No

Do you bleed excessively from minor cuts?

Yes

No

Do you have any seizure-related conditions?

Yes

No

Do you have a tendency to faint or become dizzy?

Yes

No

Do you have prosthetic implants?

Yes

No

Do you consume aspirin daily?

Yes

No

Are you under treatment for depression?

Yes

No

Do you have any type of herpes?

Yes

No

If you have any permanent cosmetics or tattoos, did you have any problems healing from them?

Yes

No

Are you currently undergoing radiation or chemotherapy?

Yes

No

Do you have a pacemaker?

Yes

No

Do you take prescription medications?

Yes

No

Please list medications if yes

Are you now, or have you ever been, on the acne medication Accutane?

Yes

No

Are you anemic?

Yes

No

Do you have any medical conditions that have resulted in a physician requiring you to pre-medicate with an antibiotic prior to a dental or other invasive procedure?

Yes

No

Do you have dry eyes?

Yes

No

Do you have glaucoma or any other eye disease?

Yes

No

Do you intentionally tan?

Sun

Tanning Bed

No

Do you have a personal history of cancer?

Yes

No

Do you have a personal history of stroke or heart attack?

Yes

No

Do you have any heart conditions?

Yes

No

To your knowledge, are you allergic or resistant to over the counter numbing products such as ELA-Max?

Yes

No

Do you have arthritis?

Yes

No

Do you have high or low blood pressure?

High

Low

N/A

Do you have sinus problems?

Yes

No

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