CLIENT CONTACT INFORMATION


PHONE NUMBERS


EMERGENCY CONTACT


If friend/family member, please specify name.


CLIENT MEDICAL INFORMATION

AREAS OF INTEREST

PREVIOUS COSMETIC PROCEDURES

GENERAL HEALTH QUESTIONS


MEDICATIONS


ALLERGIES


FOR OUR FEMALE PATIENTS


MEDICAL HISTORY


SURGICAL HISTORY

SOCIAL HISTORY


SKIN-RELATED HEALTH QUESTIONS

HERITAGE

(Example: Asian, Northern European, Indigenous, Jamaican etc.)


FITZPATRICK SCREENING SKIN TYPE


SKIN HISTORY


CURRENT SKIN CARE


I certify that the preceding personal, medical, and skin history statements are true and correct. I am aware that it is my responsibility to inform the treatment provider 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.