Skin Care Pre Treatment Consultation Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

Date

Gender

Please list the food that you are allergic to

Please list the medications you are allergic to

Do you have any of the following conditions in the last 14 days?

Please note that if you have any of the following conditions above, we recommend that you stay at home. In case you are under self-isolation, we understand the situation. In both cases, we shall make arrangements for your new schedule.

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I hereby declare that information provided above is correct and true, to the best of my knowledge. I understand my full and sole liability to this undertaking and I give my full consent to the treatment with full understanding of any possible consequences. I hereby release, waive, and discharge the clinic from any and all liabilities, damages, or any causes of action from which may be a result of my participation. I am signing and submitting this form with full knowledge and understanding that this consent shall bind me.

Signature

Date

Rows	Yes	No
Shortness of breath
Persistent Cough
Runny nose
Sneezing
Sore throat
Loss of taste or smell
Fever
Joint and muscle pains