Medical History


Birth Date:

Street Address:



Zip Code:

Mobile Phone:


Emergency Contact:

Are you now or have you been under the care of a physician within the last two years?

¬†Physician’s contact:

How did you hear about us?:

Please check any of the following medications you are currently or have previously used


Please check any allergies you have


Please check any conditions you have had

Are you receiving Chemotherapy or Radiation?

Do you wear contact lenses?

Do you tan regularly?

Do you have any tattoos?

Do you smoke?

Leave this empty:

Signature Certificate
Document name: Medical History
Unique Document ID: d25d309f477e585d6888ebd4ab6fc111b7c138d9
Timestamp Audit
June 17, 2018 11:20 am CDTMedical History Uploaded by ARD Studio Permanent Cosmetics - IP