Date: ___________ Name: _______________________________________________________________
Date of Birth: ______________________
Address: _________________________________________________________________________________
Phone:______________________ E-mail address: ____________________________________________
Referred by: ______________________________ Promotion interest _______________________________
Are you Currently Under the Care of a Physician or Dermatologist No Yes
If Yes, List For What? _____________________________________________________________________
MEDICAL HISTORY: Please circle any that apply to you.
• Pregnancy or nursing
• Under 18 years of age
• Pacemaker or internal defibrillator
• Permanent implant in the treated area such as metal plates and screws, silicone implants or an injected
chemical substance
• Current or history of cancer, especially skin cancer, or pre-malignant moles
• Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of
immunosuppressive medications
• Severe concurrent conditions such as cardiac disorders, epilepsy, uncontrolled hypertension, and liver or
kidney diseases
• A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area
• Any active condition in the treatment area, such as sores, psoriasis, eczema and rash as well as
excessively/freshly tanned skin
• History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin
• Any medical condition that might impair skin healing
• Poorly controlled endocrine disorders, such as diabetes or thyroid dysfunction
• Any surgical, invasive, ablative procedure in the treatment area in the last 3 months or before complete healing
• Superficial injection of biological fillers in the last 6 months, or Botox in the last 2 weeks
• Use of Isotretinoin (Accutane) ,Retin A , Hydroquinone
• Recent Dental Work or tooth infection
• Recent Sun exposure or use of Self Tanners
CLIENT INITIALS __________________
MEDICATIONS AND SUPPLEMENTS: NONE Birth Control Pills Hormones
Ginko Biloba Fish Oil Vitamin E Others:____________________________________________
MEDICATION ALLERGIES: NONE Latex Lidocaine/Benzocaine/Tetracaine Accutane or Retin-A Others: ____________________________________________________________________________________
SKIN TYPE : Which of the following best describes your skin after 30 minutes of sun without any SPF:
Always burns easily, never tans with very pale skin tone
Always burns, tans with a hint of color with very pale skin tone
Burns initially, tans gradually with light skin tone
Can burn and can tan with olive/gold skin tone
Rarely burns with brown skin tone
Rarely burns with very deeply pigmented skin tone
YOUR ETHNICITY:
What areas of concern do you have regarding your skin? ______________________________________________
What procedures are you interested in? Check all that apply
Dermal filler Skin Resurfacing
Botox/Xeomin/Dysport Microneedling
Vampire Facial Spray Tanning
Cellulite Treatment Microdermabrasion
Body Shaping IPL brown spots or redness
Tattoo Removal Massage
Laser Hair Removal
In the last 4 weeks, have you had injections such as Botox™, Restylane™ or Collagen or ANY FACE TREATMENT?? No Yes ___________________________________________________________________
I verify that I have read and completed this questionnaire truthfully. I understand withholding information may result in contraindications and complications for which I may be responsible and hold Skin Damsel harmless
CLIENT SIGNATURE _______________________________________________
Date: ___________ Name: _______________________________________________________________
Date of Birth: ______________________
Address: _________________________________________________________________________________
Phone:______________________ E-mail address: ____________________________________________
Referred by: ______________________________ Promotion interest _______________________________
Are you Currently Under the Care of a Physician or Dermatologist No Yes
If Yes, List For What? _____________________________________________________________________
MEDICAL HISTORY: Please circle any that apply to you.
• Pregnancy or nursing
• Under 18 years of age
• Pacemaker or internal defibrillator
• Permanent implant in the treated area such as metal plates and screws, silicone implants or an injected
chemical substance
• Current or history of cancer, especially skin cancer, or pre-malignant moles
• Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of
immunosuppressive medications
• Severe concurrent conditions such as cardiac disorders, epilepsy, uncontrolled hypertension, and liver or
kidney diseases
• A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area
• Any active condition in the treatment area, such as sores, psoriasis, eczema and rash as well as
excessively/freshly tanned skin
• History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin
• Any medical condition that might impair skin healing
• Poorly controlled endocrine disorders, such as diabetes or thyroid dysfunction
• Any surgical, invasive, ablative procedure in the treatment area in the last 3 months or before complete healing
• Superficial injection of biological fillers in the last 6 months, or Botox in the last 2 weeks
• Use of Isotretinoin (Accutane) ,Retin A , Hydroquinone
• Recent Dental Work or tooth infection
• Recent Sun exposure or use of Self Tanners
CLIENT INITIALS __________________
MEDICATIONS AND SUPPLEMENTS: NONE Birth Control Pills Hormones
Ginko Biloba Fish Oil Vitamin E Others:____________________________________________
MEDICATION ALLERGIES: NONE Latex Lidocaine/Benzocaine/Tetracaine Accutane or Retin-A Others: ____________________________________________________________________________________
SKIN TYPE : Which of the following best describes your skin after 30 minutes of sun without any SPF:
Always burns easily, never tans with very pale skin tone
Always burns, tans with a hint of color with very pale skin tone
Burns initially, tans gradually with light skin tone
Can burn and can tan with olive/gold skin tone
Rarely burns with brown skin tone
Rarely burns with very deeply pigmented skin tone
YOUR ETHNICITY:
What areas of concern do you have regarding your skin? ______________________________________________
What procedures are you interested in? Check all that apply
Dermal filler Skin Resurfacing
Botox/Xeomin/Dysport Microneedling
Vampire Facial Spray Tanning
Cellulite Treatment Microdermabrasion
Body Shaping IPL brown spots or redness
Tattoo Removal Massage
Laser Hair Removal
In the last 4 weeks, have you had injections such as Botox™, Restylane™ or Collagen or ANY FACE TREATMENT?? No Yes ___________________________________________________________________
I verify that I have read and completed this questionnaire truthfully. I understand withholding information may result in contraindications and complications for which I may be responsible and hold Skin Damsel harmless
CLIENT SIGNATURE _______________________________________________
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