Patient History Form

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Occupation

How did you hear about us?

Ethnic Background

what brings you to URVASHI BEAUTY SALON & SPA?

Do you have any chronic medical conditions which we should know about?*

YesNo

If so, Please List:

Do you have any allergies to medications, herbal or natural supplements?*

YesNo

If so, Please List:

Have you ever been treated with laser, microdermabrasion, chemical peel, or injections?

YesNo

If so, Please List:

Are you smoker?

YesNo

Do you have a history of hypo/hyper-pigmentation?

YesNo

Do you have a history of cold sores, fever blisters or herpes 1 or 2?

YesNo

Do you have veneers on your teeth?

YesNo

Please tell us about your skin (Check all that applies):

Have you had any recent sun exposure in the past 4-6 weeks, including tanning beds, bronzing creams or spray-on tans?

YesNo

If so, Please List:

Signature*

Date*

MonthDayYearHourMinutesAM/PM Option

URVASHI BEAUTY SALON * SPA