Client Information and Medical History



2590165-25717500CLIENT INFORMATION & MEDICAL HISTORYIn order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All information is strictly confidential.PERSONAL HISTORYClient Name Today’s Date__________________________________Date of Birth_____________AgeOccupation_________________________________________________Home Address______________________________________________________________________________________City____________________________________State____________________Zip Code __________________________Cell Phone ( )__________Home Phone ( )___________________Work Phone (____)__________________Email: _________________________________Emergency Contact Name &Phone_______________________________How did you hear about us??? Sublime Website ? Newspaper ? Billboard ? Magazine ? TV ?Online Search ?Sublime Facebook Page ??Facebook Advertising ? A Friend, who? ___________________? Other ____________What other services are you interested in? ? Wrinkle Reduction ? Body Contouring/ TruSculpt? Lash Enhancement ? Acne Treatment ? Botox/ Dysport? Skin Care Products ? Hydrafacial ? Dermal Filler? Mineral Make-up ? SkinPen/PRP ? Spray Tanning ?Body Waxing ? Chemical Peel??? Sclerotherapy/Spider Vein Removal ? Scar Reduction ? Laser Hair Removal ? Skin Tightening ?? Stretch Mark TreatmentMEDICAL HISTORYAre you currently under the care of a physician? ?NO ? YesIf yes, for what____________________________________________________________________________________________________________________________Have you ever had an allergic reaction? ?No ?Yes If yes, please check any and all that you have had and describe the reaction you experienced. __________________________________________________________________________________________________?Food ?Animal Protein ?Aspirin ?Lidocaine ?Hydrocortisone ?Hydroquinone or skin bleaching agents ?Others: _________________________________________________________________________________________Do you have any of the following medical conditions? (Please check all that apply)?Cancer ?Diabetes ?High blood pressure ?Herpes ?Arthritis ?Frequent cold sores ?Seizure disorder ?HIV/AIDS ?Keloid scarring ?Skin disease/Skin lesions ?Blood clotting abnormalities ?Hepatitis ?Hormone imbalance ?Thyroid imbalance ?Any active infectionDo you regularly sun bathe or use tanning salons? ?No ?Yes If yes, how often? ______________________________Do you have any other health problems or medical conditions???No ?Yes If yes, please list ___________________ For our female clients:Are you pregnant or trying to become pregnant? ?No ?Yes Are you breastfeeding? ?No ?YesAre you using contraception? ?No ?YesMEDICATIONSWhat oral prescription medications are you presently taking? ?Birth control pills ?Hormones ?Others (It is required that you list all of them): ____________________________________________________________________________________________________________________________________________________________Have you ever used Accutane? ?No ?Yes If yes, how long ago? __________________Are you currently on Antibiotics? ?No ?Yes If yes, please list ___________________________________________Do you take any medications for heart conditions? ?No ?Yes If yes, please list_______________________________Are you on any mood altering or anti-depression medications? ?No ?Yes If yes, please list______________________What topical medications or creams are you currently using? ? RetinA ? Renova ? Triluma ?Others (Please list): __________________________________________________________________________________________________What herbal supplements do you use regularly? ___________________________________________________________How do you take care of your skin? What is your daily skin care routine? __________________________________________________________________________________________________REFUNDS & EXCHANGESOur policy is to exchange an unused service, treatment, or package/series for other services upon request. Cash refunds are not available. In the event that a package or series of treatments has begun, the services will be considered to have been rendered even though the full series may not have been completed. Should you wish to discontinue your treatment in the midst of a series, credit for the pro-rated share of unused treatments at the discounted package price may be extended, and this may be used to purchase other treatments offered at Sublime. We do not issue refunds for any product or service that has been injected or used in your treatment. In consenting to be treated, it is important that clients understand and accept this condition. We are happy to do the best we can to be as flexible as possible to fit your needs. Please initial ___________CANCELLATION POLICYIt is required to give 24 hour notice for appointment cancellations. If 24 hour notice is not given, you will forfeit 500 Sublime reward points. Please initial ____________I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor or other health professional of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.Signature_____________________________________________________Date: ________________________________ ................
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