Skin Lightening Intake Form

First name

Last name

Phone

Email

Date Of Birth

Occupation

Address

How did you hear about us?

Medical History (Choose all that apply)

Please explain your medical conditions

List any cosmetic procedures you have had in the past. This includes history of fillers, botox, pdo threading, plastic surgery, or any cosmetic reconstruction.

List any medications including vitamins you are currently taking

List all allergies

Are you pregnant or lactating?

Yes

No

Not Applicable

Are you trying to get pregnant?

Yes

No

Not Applicable