LTR Medical History

Client Name (required)

Today's Date

Date of Birth

Age

Occupation

Home Address

City

State

Zip

Home Phone

Cell Phone

Email (Required)

Emergency Contact Name and Phone

HOW YOU HEARD ABOUT US

How did you hear about us?
(Please choose one)INTERNET SEARCH (Google/Yahoo/MSN)OTHERREFERRED BY

Search Term Used:

OTHER / REFERRED BY:

TATTOO AND SKIN INFORMATION

Which of the following best describes your skin type?I - Caucasian, fair skin, light eyesII - Caucasian, fair to tan skin, medium eyesIII - Darker Caucasian, light Asian, Tan complexionIV - Mediterranean, Asian, HispanicV - Middle Eastern, Light-skinned African, South AsianVI - Dark-skinned African

How old is your tattoo for removal?

Is it homemade or professional?

Short description of your tattoo(s):

MEDICAL HISTORY & MEDICATIONS

Are you currently under the care of a physician? YesNo

If yes, for what:

Are you currently under the care of a dermatologist? YesNo

If yes, for what:

Have you ever had a reaction to a previous laser treatment, heat treatment, or radiation therapy? YesNo

Do you have any of the following medical conditions? (Check all that apply)

CancerDiabetesHerpesArthritisFrequent cold soresHIV/AIDSKeloid scarringSkin disease/Skin lesionsSeizure disorderHepatitisBlood clotting abnormalitiesAny active infection

Do you have any other health problems or medical conditions? Please list:

What oral medications are you presently taking? Please List:

Have you ever taken Accutane for acne? YesNo

If yes, when did you last use it?

What topical medications or creams are you currently using?Retin-A®Others (Please list):

Have you ever had an allergic reaction to any medication? Please List:

HISTORY

Do you currently have a sunburn? YesNo

Do you form thick or raised scars from cuts or burns? YesNo

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? YesNo

If yes, please describe:

For our female clients: Are you pregnant or trying to become pregnant? YesNo

Are you breastfeeding? YesNo

CERTIFICATION

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, doctor, or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

Signature (Type Full Name to Certify)*

Date: