Name: Date of Birth:
Contact phone number:
Are you on any medications or over the counter herbal supplements?
NO YES (Please list):
Have you ever had any cosmetic treatments that have been less than satisfactory?
NO YES Please state the reasons:
Do you have any ALLERGIES or any severe allergic reactions?
NO YES Please list allergies:
Have you been told that you suffer from the following:
-Eaten Lambert Syndrome Yes No
-Multiple Sclerosis Yes No
-Bleeding disorder Yes No
-Skin conditions No Yes If Yes, please list:
Have you ever had COLD SORES? N / Y
Have you been treated with ROACCUTANE for acne in the last 6 months? N /Y
Have you had deep chemical peels or laser skin resurfacing in the past 6 months? N/Y
Have you had surgery or trauma or scarring to your face? N / Y
Are you on Vitamin E, Fish oil, Aspirin, Evening primose oil? N / Y
For Female clients: any chance you may be pregnant, planning to become pregnant or breastfeeding? N / Y
Reason for visit today:
Date: / / 20 ____