Medical History Form
This is a general intake form to be used for any medspa treatment or service.
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Patient Name
Emergency Contact


Check if you have a history or currently have any of the following medical conditions
Are you pregnant or nursing
Do you have a history of Herpes
Have you had Gold Therapy for Rheumatoid Arthritis?
Have you had surgery recently?
Have you recently used any special cream or medication to treat a skin condition?
Do you experience big mood swings, or suffer from anxiety or depression?
Do you have any permanent make up or tattoos?
Do you smoke?
Do you wear contacts?
Do you take diet pills?
Do you drink caffeinated beverages?
Do you use sunscreen?
How often do you drink alcohol?
Do you have a pacemaker or defibrillator?
Do you have metal or other implants
Do you take diuretics or laxatives
What type of skin do you have?
Do you use self tanning lotions?
Skin type, or when exposed to the sun WITHOUT PROTECTION for about an hour:
What methods do you have or have you used for hair removal?
Have you previously had laser treatment?
Have you previously had microneedling?
Have you previously had a chemical peel?
Have you previously had Botox?
Have you previously had Facial Filler?
Do you experience skin breakouts?
May we take photos for your personal file?
Medical History Terms & Conditions

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.
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