Microdermabrasion Medical History Form

Full Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How would you describe your skin?

Have you had the following procedures in 2-4 weeks?

Are you currently under a doctor’s care?

YesNo

Do you have a skin care routine?

YesNo

Do you suffer any of the following diseases?

Are you currently taking any of these medications?

When was your last exposure to the sun?

Circle your skin type when exposed to the sun for 1-2 hours without sunscreen.

Are you planning a vacation in the sun soon?

YesNo

Are you pregnant, lactating, or planning a pregnancy soon?

YesNo

Anything you would like to add?

TERMS AND CONDITIONS

I understand, have read and completed this medical history form truthfully.

I agree that the withholding information or providing misinformation may result in contradication or irritation to the service being reveived.

I declare that the above information I have given concerning my health is correct.