Consultation online form
Please take a minute to fill in the following info and Comfortable Skin's staff will follow up with your online consultation. After completing form please allow staff 2hrs for follow up. If after office hours, follow up will be the next business day.
First Name
Last Name
Email
Phone Number
Address
Which of the following best describes your skin type? Please select one skin type
I-Always burns, never tans
II-Always burns, sometimes tans
III-Sometimes burns, always tans
IV-Rarely burn, always tans
V-Brown, moderately pigmented skin
VI-Dark Brown-profusely pigmented skin
Are you currently under the care of a physician/dermatologist
yes
no
Do you have a history of erythema ab igne, which is a persistent skin rash produced by prolonged or repeated exposure moderately intense heat or infrared irradiation?
yes
no
Do you have a any of the following medical conditions? (please check all that apply)
cancer
diabetes
high blood pressure
herpes
arthritis
frequent cold sores
hormone imbalance
thyroid imbalance
blood clotting abnormalities
any active infection
not applicable
Do you have any other health problems or medical conditions? Please List:
What oral medicals are you presently taking?
Accutane
birth control pill
hormone therapy
Not applicable/no oral medication
If Accutane used, when did you last use?
What topical medications or creams are you currently using?
Have you ever had laser hair removal or laser treatments in past?
yes
no
Have you used the following hair removal methods in the past four weeks?
shaving
waxing
electrolysis
plucking
tweezing
stringing
depilatories
laser
Have you had any recent tanning lotions/treatments or recent prolonged exposure to sun or UV light tanning
yes-I have recently used tanning lotions/treatments
no -I have not recently used tanning lotions/treatments
yes-I have had exposure to sun or UV light tanning recently
no-I have not had exposure to sun or UV light tanning recently
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma?
yes
no
Female clients: Are you pregnant or trying to become pregnant?
yes
no
Are you breastfeeding?
yes
no
Please list Allergies: (If no known allergies please enter none)
What type of aesthetic service are you interested in (laser hair removal, microneedling, etc)? Where do you want (body location) treatment?
List medications; Type NA if not applicable
92
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the nurse of my current medical or health conditions and to update this history
Your Signature
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