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Client Light Medical & Treatment Intake Form

1. Personal Details

Date of Birth
Day
Month
Year

2. Skin Profile

Skin type
dry
oily
combination
sensitive
unsure
Any known skin allergies or reactions?
yes
no
Any active breakouts, eczema, dermatitis, or wounds?
yes
no
Are you currently using retinol, acids, or active skincare?
yes
no

3. Medical & Wellness Check

Are you currently taking any medications?
yes
no
Do you take any herbs?
yes
no
Do you have asthma, epilepsy, diabetes, or cardiovascular issues?
yes
no
Do you have metal implants or pacemaker?
yes
no
Do you have varicose veins, swelling, or lymphatic issues?
yes
no
Are you pregnant or breastfeeding?
yes
no
Have you had facial/body treatments in the last 2 weeks?
yes
no
Do you have a history of fainting during treatments?
yes
no

4. Treatment Safety

Any sensitivity to heat or cold?
yes
no
Do you have high or low blood pressure?
yes, low blood pressure
yes, high blood pressure
no
Have you recently used sunbeds or been exposed to the sun?
yes
no
Are you currently under medical care?
yes
no

5. Consent

  • I confirm that all information provided is correct.

  • I understand the nature and purpose of the selected treatment.

  • I agree to follow post-treatment recommendations.

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