Cosmetic/Aesthetic History Consultation Form

 


 

 


(type none if not applicable)

 

What procedures are you interested in today?

 

 

 


 

 


 

What brand of products are you currently using?

(type none if not applicable)











Please check any skin or body conditions that may apply:

Are you taking any of the following medications? Please check all that may apply:

Are you allergic to any of the following? Please check all that may apply:

 


(type none if not applicable)

 

Do you wear contact lenses?

Are you claustrophobic?

Do you have a pacemaker?

 


(type no if you are not interested)