New Client Form Tattoo Removal Confidential ... - Skin Intentions Inc

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New Client Form Tattoo Removal Confidential ... - Skin Intentions Inc Powered By Docstoc
					                                               Skin Intentions Inc
                        Confidential History for Tattoo Lightening/Removal
Name: ________________________________________________________________ Birthdate: ___/___/___
            Street                                City                     State       Zip
Home phone: _______________________ Cell: _________________________ Work: ______________________
Employer: ___________________________________________ Occupation: ______________________________
Physician Name: ______________________________________ Phone: _________________________________
Emergency Contact: ____________________________________ Phone: _________________________________
Email: _______________________________________________ Referred by: _____________________________

Do you now have or have you ever had any of the following? Please circle YES or NO.
Yes No Under physician’s care for any medical condition     Any communicable disease                                  Yes   No
Yes No High or Low blood pressure (please circle)           Ever had cold sores                                       Yes   No
Yes No Eczema                                               Herpes                                                    Yes   No
Yes No     Psoriasis                                        Bleed or bruise easily                                    Yes   No
Yes No Acne                                                 Problems healing from minor wounds                        Yes   No
Yes No     Taken Accutane in the last 6 months              Develop keloids or hypertrophic scars                     Yes   No
Yes No Skin Cancer                                          Faint or become dizzy                                     Yes   No
Yes No Vitiligo                                             Currently on radiation or chemotherapy treatment          Yes   No
Yes No     Rosacea                                          Asthma                                                    Yes   No
Yes No Dermatitis                                           Hemophilia                                                Yes   No
Yes No     Hyperpigmentation (darkening of skin)            Under treatment for depression                            Yes   No
Yes No Hypopigmentation (lightening of skin)                Currently on prescription or recreational drugs           Yes   No
Yes No     Plastic surgery or contemplating plastic surgery Tan in direct sun or tanning bed                          Yes   No
Yes No Any medical implants                                 If you tan, do you burn easily                            Yes   No
Yes No Any type of heart disease or stroke                  Are you pregnant or nursing                               Yes   No
Yes No     Any seizure related condition                    Do you take herbal supplements                            Yes   No
Yes No Wear a pacemaker                                     Problems with dental anesthesia                           Yes   No
Yes No     Diabetes                                         Smoke? Quantity per day________                           Yes   No
Yes No Autoimmune disorders                                 Alcoholic beverages? Drinks per week______                Yes   No
Yes No Hepatitis / Jaundice                                 Latex allergy                                             Yes   No
Yes No     HIV / Aids positive                              Allergies to prescription or over the counter Medicines   Yes   No

List all prescription medications, vitamin supplements, and herbal supplements you are taking:
List all allergies to medications and other: _________________________________________________________

Signature: _______________________________________________________ Date: ___________________

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