Affordobalelazer

AFFORDABLE LASER HAIR REMOVAL
2022 West Northwest Hwy
Suite 120, Grapevine, Tx 76051.

Client Information and Health History

Hormones: (for women only)	yes No
Do you have regular periods?	yes No
Are you going through menopause?	yes No
Are you currently to become Pregnant?	yes No
Are you currently Pregnant or nursing?	yes No
Have you ever been treated by Endocrinlogist?	yes No

edical History: Please Check any that apply

	____Accutane		____Fenital Herpes
	____Acne		____Hirsutism
	____Auto Immune Disoreder (example: Lupus)		____HIV, STD’s
	____Blood Disorders(Blood Thinners)		____Hormonal Imbalance
	____Cancer		____Metal Pins in Body
	____Cold Sores		____Pacemaker
	____Dermatitis		____PCDS (Polycystic Ovary)
	____Epiliepsy		____Shingles
	____Folliculitis		____Steroid or Hormonal Therapy

Are you currently being treated for any Medical conditions not listed above?	yes No

Are you currently taking any medications? Example: antibiotics, birth control, over the counter	yes No

Have you ever used Accutane?	yes No

Do you have any allergies?	yes No

I understand that withholding information about my health could affect the outcome of my treatments or procedures; all of my health information stated above is current, accurate and true. I agree that the information listed above has been reviewed and presented with my clear and understanding of what this procedure involves.

All of my questions have been addressed to my satisfaction.

Client Signature

Date: