Telephone Work:________________________________________ Home:___________________________________ Mobile:_______________________________________ Email:___________________________________ How did you hear about us?_________________________________________________________________________ MEDICAL BACKGROUND Are you currently under Doctor’s care?
YES / NO
If yes for what? Please List any prescription or non prescription medication you are taking including anything topical or herbal ___________________________________________________________________________________________ _________________________________________________________________________________________________ Have you had surgery in the last 6 months
YES / NO
If yes please explain:________________________________________________________________________________ Are you pregnant or trying to conceive?
YES / NO
Have you got any allergies or sensitivities?
YES / NO
If yes, please explain:________________________________________________________________________________ Have you ever had any of the following treatments? Chemical Peels
YES / NO
Skin resurfacing
YES / NO
Electrolysis
YES / NO
Roaccutane therapy
YES / NO
Laser Treatment
YES / No
Intense Pulsed Light
YES / No
Photo Rejuvenation
YES / NO
If Yes when?_______________________________________________________________________________________ Have you ever experienced any of the following ? Skin Cancer Cold Sores
YES / NO YES / NO
Photosensitivity Haemophiliac
YES / NO YES / NO
Cancer Epilepsy
Keloid
YES / NO
Diabetes
YES / NO
Removal of skin Lesions YES / NO
Any skin pigment changes
YES / NO YES / NO
YES / NO
If yes, please explain and include dates:_________________________________________________________________ Note: Any changes to medical history or medications must be notified. Technician Initial:____________________________
