CLIENT INFORMATION

Address *

Would you like to be added to our email list for news and exclusive offers? *

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No

MEDICAL HISTORY

Do you have or have you had any of the following conditions? If yes, please select them:

Any chronic medical conditions? *

Are you currently on any blood-thinning prescription or non-prescription drugs? *

Yes

No

Do you have any allergies? *

Have you had any cosmetic procedures (e.g. botox, fillers, plastic surgery, reconstruction)? *

FACIAL HISTORY

What bothers you most about your facial appearance? *

What are your expectations for today's visit? *

Do you regularly sun bathe or use tanning salons? *

What topical medications or creams are you currently using? *

Have you waxed, tweezed, bleached, or used hair removal cream within the last week? *

Have you taken any Aspirin, Ibuprofen, Motrin, Tylenol, Fish Oil, Vitamin E, Blood Thinners, Alcoholic Beverages in the last 10 days? *

FACIAL INJURY TRAUMA HISTORY

Is there any history of facial surgery?

Is there any recent history of trauma to the head or face?

By signing below, you agree to the following:

I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the above information. I agree to waive all liabilities toward my technician and the employer of any injury or damages incurred due to any misrepresentation.

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