cloud 9MEDI SPA
CLIENT INFORMATION SHEET
NAME______DATE OF BIRTH______
ADDRESS______CITY:______
STATE:______ZIP:______OCCUPATION:______
EMAIL:______Referred By:______
PHONE:(DAY)______(NIGHT)______
PROCEDURES DESIRED:
BOTOX: ___FOREHEAD ___CROWS FEET ___FROWN LINES (BETWEEN EYES)
OTHER______
DERMAL FILLERS: ___LIPS ___NASOLABIAL FOLDS
MASSAGE: ___
PERMANENT MAKEUP:
___EYELINER ___EYEBROWS ___LIPLINE ___FULL LIP COLOR ___NIPPLES ___BEAUTY MARK ___SKIN REPIGMENTATION
ARE YOU CURRENTLY UNDER THE CARE OF A PHYSICIAN? ___YES ___NO
If so, why?______
PHYSICIAN’S NAME______
MEDICATIONS:______
ALLERGIES:______
DO YOU HAVE ANY OF THE FOLLOWING: ___DIABETES
___HEPATITIS ___HEART PROBLEMS ___HEMOPHILIA ___SKIN PROBLEMS
___SCARRING (KELOIDS) ___EYE PROBLEMS ___EPILEPSY ___OTHER
EXPLAIN:______ARE YOU PRESENTLY TAKING ANY MEDICATION THAT THINS THE BLOOD?
___YES ___NO
IF YES, PLEASE EXPLAIN:______
ARE YOU PREGNANT OR NURSING? ___YES ___NO
DO YOU WEAR CONTACT LENSES? ___YES ___NO
SIGNED______DATE______