Microdermabrasion Consultation Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you currently taking any medications, vitamins, herbal supplements, alcohol, tobacco or drugs?
Yes
No
Please specify
In the last one month, have you had any dermal treatments such as tattoos, dermal fillers, piercings or botulinum toxin?
Yes
No
Please specify
Are you pregnant or lactating?
Yes
No
Do you have any allergies in your knowledge?
Yes
No
Please specify
Do you have any relevant past medical history
Yes
No
Please specify
Have you recently received your COVID-19 vaccination?
Yes
No
Please select if you you suffer from any of the conditions listed below
Hypopigmentation
Hypertrophic Scarring
Epilepsy
Immunodeficiency
Rheumatic Fever
Anaphylaxis/severe allergy
Respiratory Conditions
Herpes Simplex Virus (Coldsores)
Active Acne or Inflammatory Skin Conditions
Porphyria
Sunburn
Eczema
Dermatitis
Skin Cancer
Diabetes
I.D.U.
Moles
Psoriasis
Vascular lesions
Anticoagulants
None of the them
Other
Please give details
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I confirm that all information indicated in this form is true and accurate.
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Month
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Day
Year
Date
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