First Name

Last Name

Date of Birth

Your email

Your telephone number

How were you referred to us?

Health History & Summary

Are you currently under the care of a Physician?
YesNo

Do you have any of the following medical conditions? (please check all that apply)
CancerHerpesHIV / AIDSSeizure DisorderAny Active InfectionThyroid ImbalanceRosaceaDiabetesArthritisKeloid ScarringHepatitisBlood Clotting AbnormalitiesSkin CancerHigh Blood PressureFrequent Cold SoresSkin Disease / Skin LesionsHormone Imbalance

Do you have any other health problems or medical conditions? Please list:

Are you pregnant or trying to become pregnant? YesNo

Are you breastfeeding?
YesNo

Please list any allergies you are aware of:

Please list all medications you are currently taking:

Please list current skin concerns as well as skin goals:

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the Esthetician, Clarneesha Fuller of my current medical and health history and to update any current conditions. A current medical history is essential for the esthetician to execute the appropriate treatment procedures. (All information is strictly confidential)

Your Name: THIS SERVES AS YOUR SIGNATURE

Todays Date

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