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Microdermabrasion Medical History Form -Form Fill

Section One

Full Name

First Name

Full Name

Last Name

Email

Phone Number

Address

Street Address

Address

Street Address Line 2

Address

City

Address

State / Province

Address

Postal / Zip Code

Q10

How would you describe your skin?

Q11

Have you had the following procedures in 2-4 weeks?

Q12

Are you currently under a doctor’s care?

Q13

Do you have a skin care routine?

Q14

Do you suffer any of the following diseases?

Q15

Are you currently taking any of these medications?

Q16

When was your last exposure to the sun?

Q17

Circle your skin type when exposed to the sun for 1-2 hours without sunscreen.

Q18

Are you planning a vacation in the sun soon?

Q19

Are you pregnant, lactating, or planning a pregnancy soon?

Q20

Microdermabrasion Medical History Form -Form Fill

Full Name

Full Name

Email

Phone Number

Address

Address

Address

Address

Address

How would you describe your skin?

Have you had the following procedures in 2-4 weeks?

Are you currently under a doctor’s care?

Do you have a skin care routine?

Do you suffer any of the following diseases?

Are you currently taking any of these medications?

When was your last exposure to the sun?

Circle your skin type when exposed to the sun for 1-2 hours without sunscreen.

Are you planning a vacation in the sun soon?

Are you pregnant, lactating, or planning a pregnancy soon?

Anything you would like to add?