Consultation Form

Please fill out the consultation and consent forms prior to attending your appointment. Thank you.

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Consultation Form

First Name

Last Name

Address

Emaila valid email

Phone Number

Referred by(if applicable)

ALLERGIES

Do you have any allergies? (i.e. Latex)

YesNo

If yes, please specify:your full name

Have you ever had a reaction to anesthetics?

YesNo

If yes, please specify:your full name

Have you ever had a reaction to antibiotics?

YesNo

If yes, please specify:your full name

Have you ever had a reaction to Lidocaine?

YesNo

If yes, please specify:your full name

Have you had an eye surgery?

YesNo

If yes, please specify:your full name

Please specify any other allergies or concerns:

0 /

Medical History

Survey

	Yes	No
Do you have any tattoos?
Are you Diabetic?
Do you bruise easily?
Are you currently pregnant or breastfeeding?
Do you have any heart conditions?
Does your skin swell easily?
Have you ever tested positive for HIV or Hepatitis?
Have you ever had a fever blister, cold sore, or canker sore?
Do suffer from a serious medical condition?

Please specify any other medical concerns/conditions:

0 /

Medical History

Are you currently taking any medications, including immunosuppressant such as an anti-inflammatory or steroid?

YesNo

If yes, please specify:your full name

Do you use anti-aging products that contain acids or Retinol A?

YesNo

If yes, please specify:your full name

Do you use acne products (i.e. Proactive, Salicylic acid)

YesNo

If yes, please specify:your full name

Are you able to take over-the-counter antihistamine? (i.e. Benadryl)

YesNo

Client Signature (please type your full name)your full name

Dateof appointment

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BY APPOINTMENT ONLY
Monday-Friday ~ 10-8
Saturday ~ 10-6
Sunday ~ Closed

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Consultation Form