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Name *
Address *
Cell Phone *
Please let us know how you heard about us *
Date of Birth
Email *
Home Phone
What Services are you interested in? *
Work Phone
Do you already have an appoinment scheduled? *
Are you currently under a Doctors care? *
Allergies *
Conditions *
Do you have any Metal Implants? *
Exercise(days per week) *
Alcohol Use(days per week) *
Fast Foods(days per week) *
Tobaco Use *
Water Intake(glasses per day) *
Ethnic Background *
Your Eye Color *
Natural Hair Color *
How does your face react to sun? *
What happens when you stay in the sun too long? *
To what degree do you turn brown? *
Do you turn brown within several hour of sun explosure? *
Do you have freckles on unexpose skin? *
Last time you exposed yourself to the sun/tanning bed? *
Do you exposed the areas to be treated to the sun? *
Color of non exposed skin *
I have read and understand the medical history information and have answered all questions accurately and to the best of my konwledge. *
