New Client Medical Background Information
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Name *
Date of Birth *
DD
/
MM
/
YYYY
Occupation
Full Address (Street/City/State/Zip) *
Phone Number *
Emergency Contact (Name & Number) *
How were you referred to us? (if Friend, please list their name) *
Are you currently under the care of a physician? *
If yes, please explain why
Do you have any of the following medical conditions?  Please check all that apply *
Required
Please list any other medical conditions
Have you ever had an allergic reaction to any of the following?  Please check all that apply. *
Required
If you marked yes to any allergic reactions, pleaes describe the reaction here.
What oral medications are currently taking? *
Required
If you chose other, please list:
Are you on mood altering, or anti-depressant medication? *
Are you using any products with Retin-A? *
What topical medications or creams are you using? *
What herbal supplements do you take regulary? *
Are you pregnant, or trying to get pregnant? *
Are you currently breastfeeding? *
I certify that the preceding medical, personal, and skin history are true and correct. I am aware that is it my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history.  A current medical history is essential for the caregiver to execute appropriate treatment procedures. I agree to electronically sign this document by entering my name and date, and understand this is in place of a handwritten signature *
I have received the documentation from True Skin, titled "Consent for Cavi Lipo or Endy Med treatment,"  explaining to me the procedure, and my responbilities. *
If I am receiving Cavi Lipo, I have received the document labeled, "Pre & Post Treatment." I understand my commitment to cavi lipo, and will do my part to maximize my results.  I understand by not following these guidelines, I may not see results with the treatment. *
By signing below, I have read and understand all the information presented to me before consenting to treatment. And I have had all my questions answered. I understand the procedure and accept the risks.  I hereby release Dawn Kalin (individual), True Skin (the facility), and Dr. Steven Kohn (doctor) from all liabilities associated with the above indicated procedure. Please write your name and date (MM/DD/YYYY) *
By signing below, I understand and accept that any appointment that I cancel without proper 24 hour notice, or simply do not show up for may be subjected to a $45 cancellation fee. I also understand that if I am more than 10 minutes late for my appointment, I may need to be rescheduled. Please write your name and date (MM/DD/YYYY) *
By signing below, I give consent for True Skin to use my before and after photos in their marketing without compensation. Please write your name and date (MM/DD/YYYY)
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