Contact InformationName First Last Date of Birth* DD slash MM slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code Email* General InformationGender* Female male 1. Are you currently under the care of a Physician?* Yes No If yes, what for?*2. Are you currently under the care of a Dermatologist?* Yes No If yes, what for?*3. Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure moderately intense heat or infrared irritation?* Yes No 4. Do you have any of the following medical conditions? (check all that apply) Cancer Diabetes High blood pressure Herpes Arthritis Frequent cold sores HIV/AIDS Keloid scarring Skin diseases/lesions Seizure disorder Hepatitis Hormone imbalance Thyroid imbalance Blood clotting abnormalities Any active infection 5. Do you have any other health problems or medical conditions? Please list:6. Have you ever had an allergic reaction to any of the following? (check all that apply) Food Latex Aspirin Hydrocortisone Hydroquinone Lidocaine Others Please Explain* Medications7. What oral/topical medications are you presently talking? Birth Control pills Hormones Other Please Explain* 8. Are you on any mood altering or anti-depression medication?* Yes No 9. Have you ever used Accutane?* Yes No If yes, when did you last use it?*10. Do you use any herbal supplements regularly?* Yes No If yes, please explain:*History11. Have you ever had laser hair removal?* Yes No 12. Have you had any recent tanning or sun exposure?* Yes No 13. Do you form thick or raised scars from cuts or burns?* Yes No 14. Do you have Hyperpigmentation (darkening of the skin), or Hypopigmentation (lightening of the skin or marks) after physical trauma?* Yes No If yes, please explain:*15. Have you ever had local anesthesia with lidocaine?* Yes No Female Clients Only16. Are you pregnant or trying to become pregnant?* Yes No 17. Are you breastfeeding?* Yes No 18. Are you using contraception?* Yes No Skin Type19. Which of the following best describes your skin type?* I Always burn, never tan II Always burn, sometimes tan III Sometimes burn, always tan IV Rarely burn, always tan V Brown, moderately pigmented skin VI Heavily pigmented skin, very dark hair Client's Signature* Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY
