New Client Form

Name *

First Name

Last Name

Are you pregnant? *

Yes

No

Do you have any metal implants? *

Yes

No

Have you used any of the following products in the last 12 months? *

Accutane

Alpha or Beta Hydroxy Acids

Botox, Restalyne or other injectable

Retinol, Retin A or Renova

Tanning bed or self-tanning lotion / spray

Other prescription product applied to skin

Are you prone to histamine reactions? *

Those prone to allergies or histamine reactions may benefit from taking an antihistamine before and after certain treatments.

Yes

No

Medical Information *

Bleeding or Bruising

Pacemaker

Implanted Defibrilator

Seizure Disorder

Headaches/Migraines

Sinus Problems

Environmental Allergies

Diabetes

Hepatitis

HIV/AIDS

Skin Cancer or Other Cancer

Rosacea

Eczema

Psoriasis

Lupus

Keloid Scars

Claustrophobia

None of the above