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Consultation Form

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Day
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Birthday
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MEDICAL HISTORY

Please mark any of the following conditions you may currently have.
Do you have any allergies?
Yes
No
Are you currently taking blood thinning medication?
Yes
No
Are you currently pregnant or trying to get pregnant?
Yes
No
Do you have any implants?
Yes
No
Have you had any Botox/ Dermal Filler treatments recently?
Yes
No
Have you had any adverse reactions to any previous treatment?
Yes
No
Have you exfoliated or applied any products to your face in the last 24 hours?
Yes
No
Have you had any allergic reactions to any of the following?
COSMETIC TREATMENT OR SURGERY HISTORY:

By signing below, you agree to the following:


I have completed this form truthfully and to the best of my knowledge. I agree to waive all liabilities toward my medical members and the employer for any injury or damages incurred due to any falsification of my medical history.

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