Name:                                                                   

Date of Birth:

Address:

Contact phone number:

This information is protected and will not be distributed without formal consent.

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 only: is there any chance you may be pregnant, planning to become pregnant or currently breastfeeding?

NO              YES

Reason for visit today:

Signature:                                           

Date: / / 20 ____