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Client Information & Medical History
In order to provide you with the most appropriate laser treatment, we need you to complete the following questionnaire. all information is strictly confidential.
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Email
*
Your email
Name
Your answer
Today's Date
MM
/
DD
/
YYYY
Age
Your answer
Occupation
Your answer
Home Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Cell Phone
Your answer
Email
Your answer
Emergency Contact Name and Phone
Your answer
How were you referred to us?
Your answer
Which of the following best describes your skin type? (Choose one type)
I - Always burns, never tans
II - Always burns, sometimes tans
III - Sometimes burns, always tans
IV - Rarely burns, always tans
V - Brown, moderately pigmented skin
VI - Black Skin
Clear selection
Do you regularly use tanning salons or sun bathe?
Yes
No
Clear selection
If yes, how often?
Your answer
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