PATIENT PROFILE & MEDICAL HISTORY Name _____________________________ Birthday________________ Age ____ Address_________________________________ State______ Zip_____________ E-Mail Address______________________________________________ Sex M / F Phone_____________________________________________________________ Home Cell Work Primary Doctor____________________________________ Phone_____________ Emergency Contact___________________________________________________ Name Phone Relationship ------------------------------------------------------------------------------------------------------------Allergies Food & Medicine_____________________________________________ __________________________________________________________________ Current Medication___________________________________________________ ___________________________________________________________________ Do you have any chronic, underlying health problems? Y / N _________________ ___________________________________________________________________ Do you have any hormonal disorders? Y / N ______________________________ Are you pregnant or lactating? Y / N Are your menstrual periods regular? Y / N Do you have a history of keloid scaring? Y / N Do you have a history of herpes I or II in the area to be treated? Y / N Do you have any implants, tattoos, or permanent make-up? Y / N Please list: ___________________________________________________________________ Have you taken Accutane or Anticoagulants in the last 6 months? Y / N Do you use any topical medications? Y / N Please list_______________________ Do you use tanning beds or self tanners? Y / N Date of last sun/tanning bed exposure? __________________________________ Do you smoke? Y / N How long? _______________________________________ Do you have an internal pacemaker? Y / N ------------------------------------------------------------------------------------------------------------Please circle all that apply Have you ever had a peel? Yes No Date___________ Facial Surgery/Laser resurfacing? Yes No Date___________ Botox Injections? Yes No Date___________ Cosmetic Fillers? Yes No Date___________ Leg Vein Treatments? Yes No Date___________ ___________________________________________________________________ How did you hear about us? ___________________________________________ ___________________________________________________________________ Patient Signature ___________________________________ Date_____________ __________________________________________________ Date____________ Guardian if under 18 Relationship I acknowledge that the above information to be true to the best of my knowledge and understand that providing information that is less than accurate may result in personal injury. _________ Initial -2-