Client Medical Form

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Client Information

Please list any medications you are currently taking:

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Full Name *

First

Last

Age *

Phone *

Email *

Appoinment Date *

Date

Time

Address *

Address Line 1

City

State

Client Medical History

Please list any medications you are currently taking:

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Please fill out the following information:

History of MRSA
Keloid scarring
Currently pregnant or breastfeeding
Hepatitis A, B, C or D, AIDS, HIV
Herpes simplex
Immunodeficiency
Abnormal Heart Condition
Diabetes
Chemotherapy/ Radiation Therapy
Sensitive to regular makeup and dyes
Accutane or Acne Treatment
Tumors/ Cysts

I agree that all the above information is true and accurate to the best of my knowledge.

Hemophilia
Anemia
Accutane/Retin-A
Eyebrow growth serum
Cold sores
Botox treatment for the past 30 days
Brow lift
Chemical Peel
Oily skin
Tanning
Breast-feeding / Pregnant

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Cancer (if yes, what year? .................. )

Yes
No

Answer *

Allergies to any medication, if yes, please list:

Yes
No

Answer *

Any diseases or disorders not listed, if yes, please list:

Yes
No

Answer *

Allergies to any metals, food etc. if yes, please list:

Yes
No

Answer *

In Case of Emergency

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Full Name (In Case of Emergency) *

First

Last

Relationship to Client (In Case of Emergency)

Phone (In Case of Emergency)

Comment or Message

Signature *

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URL

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