Confidential Client Health History Form For All New Clients 

Please answer all questions:

Have you been under the care of a physician, dermatologist, or other medical professionals within the past year?
Any recent surgery including plastic surgery?
Have you had any piercings, tattoos, or permanent cosmetics?
Have you ever had a body treatment before?
Has your physician discussed concerns about raising your body temperature?
Do you smoke?
Do you follow a restricted diet or exercise program?
Use of any acne medications?
Do you have hyperpigmentation or hypopigmentation?
Do you experience any sleeping problems?
Do you have metal implants or a pacemaker?
Do you have sinus problems?
Have you had any of these health conditions in the past or present?

Please answer all questions:

What is your stress level?
List your daily consumption of:
Exposure to sun/ tanning bed:
Experience any of these adverse reactions after using any skincare products:
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Female Clients Only:

Are you taking oral contraceptives?
Any recent changes to your contraceptive treatment?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?
Upload Patient/parent/guardian (signature): *

Thanks for submitting!