Medical History Form

Personal Information

Client Name*

Today's Date*

Your Date of Birth*

Age*

Occupation*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Home Phone Number*

Work Phone Number*

Mobile Phone Number

Emergency Contact Name*

Emergency Contact Phone*

How were you referred to us?*

Which service are you looking for?*

Electrolysis
Laser Hair Removal

What area would you like treated?*

Have you ever had laser or electrolysis treatments in the past?*

Yes
No

Medical History

Are you under a doctor's care now?*

Yes
No

If "yes", for what?*

Have you been treated with hormone medications?*

Yes
No

If "yes", indicate the specific hormone medication*

Are you taking any prescription medication, including any topical?*

Yes
No

If "yes" please list all medications:*

Are you using Biotin, Rogaine or other products like Rogaine?*

Yes
No

Do you have any tattoos or permanent makeup in areas to be treated?*

Yes
No

Have you had surgery in the last 12 months?*

Yes
No

If "yes", please explain:*

Have you had a skin check?*

Yes
No

If "yes", when?*

Are you sensitive to any soaps, ointments or lotions?*

Yes
No

Does your skin get blotchy, red, or irritated easily?*

Yes
No

Do you have an artificial tan or have you had significant sun exposure in the last 4-6 weeks?*

Yes
No

If "yes", please explain:*

If "yes", please describe:*

Have you ever had a chemical peel?*

Yes
No

Are you currently pregnant, breastfeeding or trying to conceive?*

Yes
No

Do you have any of the following medical conditions?*

Form Completion

I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor or other health professionals of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment.

When you select the button below, you will be taken to a screen to sign this document electronically. If you are unfamiliar with electronic signatures, please watch this short video.

Personal Information

Medical History

Form Completion

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