top of page

Consultation/
Medical Info Intake Form

How did you hear about us?

Medical/Personal Information

[If you do not have a provider, please answer "n/a"]

Have you ever had body contouring or vacuum therapy treatments before?
Are you pregnant, trying to get pregnant, nursing or is there a chance you might be?
Do you currently have a hernia?
Do you have a pacemaker, or internal metal device (ie rods, plates, screws) ?
Do you bruise easily?
Are you taking any blood thinners ie asprin, warfarin, coumadin?
Have you ever been treated with Accutane, Isotretinoin, or Retin-A?
Do you exercise?

Medical History

Family History (select all that apply)

Treatment History

Are you currently being treated by a health care provider? (select all that apply)
Have you had prior plastic surgery of the face or body?
Have you had prior neurotoxin?
Have you had prior dermal filler?
Have you had prior permanent make-up services?

Do you have any history of the following pre-existing conditions?

I certify that the preceding medical, personal, and skin history statements are true and correct to best of my knowledge. I am aware that it is my responsibility to inform my technician of my past or current medical history in order for my technician to have the most current information on hand.

Please answer the following questions so we can better service you:

What treatments are you interested in? [check all that apply]

Which most closely describes your:

List all skincare products that you use:

Reaction to the sun with no protection? [choose one from the dropdown]
Skin, hair, eye pigmentation? [choose one from the dropdown]
What are your main concerns? [check all that apply]
bottom of page