Medical History Form Name * First Name Last Name Date of birth * MM DD YYYY Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Do you have any allergies? * Are you currently taking any medications? * Do you have any skin conditions? * Have you had any previous facial aesthetics? If yes, please specify treatments and dates? * Do you have any chronic illnesses? * Are you pregnant or breastfeeding? * Yes No Any other relevant medical information? * What are you hoping to achieve? * Why have you decided to do it now? * Please sign or initial * Thank you!