Client Consultation Form

  • Medical Background


  • Please list any medications and/or supplements you are currently using.

  • Note: Any changes to medical history or medications must be notified; including at follow-up treatment sessions.
  • Family History

  • The information you provide in this section will help us identify any possible pigmentation issues that may be affected by specific treatments we offer.
  • Sun exposure
  • Previous Treatment History

  • Have you ever experienced, or been treated for, any of the following? Contra Indications
  • Special Precautions
  • Have you ever had any of the following treatments?