Web & Service by Salon Industries
Service Select A Service Fibroblast Skin Treatment Laser Tattoo Removal Laser Hair Removal Chemical Peel Microdermabrasion Microneedling
Name
Date of Birth
Address
City
Province
Postal Code
Email
Home Phone
Business Phone
Cell Phone
Emergency Contact Number
How did you hear from us?
Describe the nature of your visit.
What are your expectation?
Please fill checkmark any of the following that may apply.
Include any other medications that make you photo sensitive.
List all medication you are currently taking (Blood thinners, antibiotics, herbs, supplements, vitamin, asperin etc.
List any Allergies
Select one (when exposed to the sun without protection for approximately 1 hour):
Have you waxed, used depilatories, bleaches or other chemical processes?
How much water do you normally consume daily?
Do you excercise?
Do you smoke?
Have you had microdermabrasion?
Have you had any chemical peels?
Have you had laser resurfacing?
Do you have rosacea?
Do you have wrinkle concerns?
Do you have scarring concerns?
Do you have sun damage concerns?
Do you have pigmentations concerns?
Do you have broken capillary concerns?
Do you use topical ointments?
Have you had Botox or Collagen injections in the past 6 months?
If yes, and less then 3 months, approximate dates?
What type of skin care products are you using?
By submiting this form, I agree and certify that the above medical history information is accurate and correct.
