Intake Form

Date(Required)
Service name(Required)

Waiver, Release and Consent

Client Medical Information

Do you have any allergies (e.g., latex gloves)?(Required)
Are you allergic to anesthetics?(Required)
Are you allergic to antibiotics?(Required)
Have you recently had eye surgery in the past 2 years?(Required)
Do you have any tattoos?(Required)
Are you currently pregnant or breastfeeding?(Required)
Do you have a history of keloid scarring?(Required)
Do you suffer from any serious medical conditions?(Required)
Do you have a skin condition (Rosacea or Eczema)?(Required)
Do you suffer from a thyroid condition? (Graves, Hashimoto, nodules etc.)(Required)
Are you diabetic?(Required)
Have you ever taken Accutane for skin treatment either currently or in the past?(Required)

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