In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All medical information is confidential.
Client's Name (First):
Client's Name (Last):
Date:
Date of Birth:
Age:
Occupation:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Is it ok to text or leave a message on either number listed above?
Email:
How were you referred to us?
Emergency Contact Name & Phone:
May We Call You?
Check ALL that apply:
Pacemaker:
Metal implants:
Current or history of skin cancer / pre-cancers:
Active skin infection:
Herpes simplex:
HIV / AIDS:
Seizure disorder:
History of keloids, abnormal wound healing, vitiligo:
Bleeding disorders:
Do you take any mood altering or anti-depressant medication:
Impaired immune system:
Pregnant and/or nursing:
Accutane within the past year:
Tattoo or permanent make-up:
Endocrine disorders ie:diabetes, PCOS: