Medical Consent Form

Name*

First Last

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone

Cell Phone

Email*

Date of Birth*

How did you hear about us?

Advanced Skin Typing Questions

Eye Colour*

Light Blue/Grey/Green
Blue Grey/Green
Blue
Hazel, Light Brown, Brown
Brown, Brownish Black

Natural Hair Colour*

Natural Skin Colour*

Reddish, Pink
Very Pale
Pale with Beige Tint
Light Brown
Dark Brown

Freckles*

Prolonged Sun Exposure*

Painful Redness, blister, peel
Burn, then peel
Some burn, then peel
Rarely burns
Never burns

Degree of Tan*

Hardly or Not At All
Light Colour Tan
Reasonable Tan
Tans Easily
Turns Dark Brown Quickly

Deeper Tan Hours After Exposure*

Face Response to Sun*

Last Exposure Tan/ Tan Cream*

3 months ago
2-3 Months Ago
1-2 Months Ago
Less than 1 month ago
Less Than 2 Weeks Ago

Sun Exposure to Treatment Area*

Parents Ethnicity

Maternal Grandparents Ethnicity

Paternal Grandparents Ethnicity

Score

Your Skin Type Number

1 0-7
2 8-16
3 17-25
4 26-30
5 Over 30

IPL Skin & Health Form

Are you under the care of a physician or ND?*

Yes
No

Details

Are you under the care of a dermatologist?

Yes
No

Details

Current medications, vitamins and/or herbs*

Allergies

Currently, any electrolysis, laser, microdermabrasion, waxing, tweezing or peels in the treatment area?

Yes
No

What and how long ago?

Have you sun tanned, or used a tanning bed in the past

2 weeks
4 weeks
Longer than 4 weeks

What topical medications or creams are you currently using?

Please Check All That Apply

Do you have any other health problems or conditions?

Acknowledgement

Certification*

I agree

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 technician, esthetician or therapist my current medical or health conditions and to update this history form. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

Name*

First Last

Signature*

Date*

CAPTCHA

Advanced Skin Typing Questions

Your Skin Type Number

IPL Skin & Health Form

Acknowledgement

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Spa Zone Hours

Spa Zone Location

Contact Spa Zone

Methods of Payment