MEDICAL FORM

Name *

First Name

Last Name

Contact Number

(###)

###

####

Birthday

MM

DD

YYYY

What Treatment are you having?

Lumecca IPL

Body Fx RF Contouring

Forma RF Skin Tightening

Microneedling

Facial

Manicure/Pedicure

Waxing/Tinting

Past Personal Medical History (Check all that apply)

Anemia

Arthritis

Artificial Joint

Autoimmune Disease

Bleeding Disorder

Blood Clots

Breast Cancer

Bronchitis

Cancer

Chronic Cough

Connective Tissue Disorder

Diabetes

Dialysis

Depression

Fibromyalgia

Heart Disease/Condition

Herpes Simplex

High Blood Pressure

HIV/AIDS

Migraines

Multiple Sclerosis

Phlebitis

Seizure Disorder

Stroke

Thyroid Disorder

Tuberculosis

Ulcers

Metal Implants

Past Personal Skin History (Check all that apply)

Undiagnosed Skin Lesions

Actinic Keratosis

Basal Cell Skin Cancer

Keloids

Connective Tissue Disorder

Serious Skin Infection

Squamous Cell Skin Cancer

Melanoma

Psoriasis

Lupus

Shingles

Eczema

Pigment Disorder

Family History (Check all that apply)

Adopted

Cancer

Autoimmune Disorder

Diabetes

Melanoma

Heart Disease

Stroke

High Blood Pressure

Skin Disease

Do you CURRENTLY have any of the following (Check all that apply)

Poor General Health

Swollen Lymph Nodes

Circulation Problems

Rashes

Non-healing Sores

Headache

Chest Pain

Numbness

Fainting

Suspicious Moles

Swollen Legs/Feet

Easy Bruising

Heat/Cold Intolerance

Flushing

Itching

Swelling

Bleeding Tendencies

Are you pregnant?

Yes

No

As an extra precaution please confirm that you are not allergic to the following (Tick if YES)

Latex

Iodine

As an extra precaution please confirm that you have not used any of these topical medications within the last 6 months (Tick if YES)

Accutane

Retin A

Refissa

Renova

Differen

Tazorac