Medical History

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

PERSONAL HISTORY

Client Name(Required)

Today's Date(Required)

Date of Birth(Required)

Age(Required)

Occupation

Home Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Home Phone(Required)

Work Phone

Emergency Contact Phone(Required)

How were you referred to us?

Which of the following best describes your skin type?(Required)

Always burns, never tans

Always burns, sometimes tans

Sometimes burns, always tans

Rarely burns, always tans

Brown, moderately pigmented skin

Black skin

Do you regularly use tanning salons or sun bathe?(Required)

How often?(Required)

CLIENT INFORMATION & MEDICAL HISTORY

PERSONAL HISTORY

MEDICATIONS

HISTORY

For Our Female Clients: