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 _______________________________________________