1. Are you currently under the care of a Physician?
2. Are you currently under the care of a Dermatologist?
3. Do you have a history of erythema ab igne (a persistent skin rash from prolonged/repeated exposure to moderate heat or infrared)?
4. Do you have any of the following medical conditions? (check all that apply)
5. Do you have any other health problems or medical conditions? Please list:
6. Have you ever had an allergic reaction to any of the following? (check all that apply)
7. What oral/topical medications are you presently taking? (check all that apply)
8. Are you on any mood-altering or anti-depression medication?
9. Have you ever used Accutane?
10. Do you use herbal supplements regularly?
11. Have you ever had laser hair removal?
12. Have you had any recent tanning or sun exposure?
13. Do you form thick or raised scars from cuts or burns?
14. Do you have Hyperpigmentation (darkening) or Hypopigmentation (lightening) of the skin after physical trauma?
15. Have you ever had local anesthesia with lidocaine?
16. Are you pregnant or trying to become pregnant?
17. Are you breastfeeding?
18. Are you using contraception?
Which of the following best describes your skin type?
I certify that the above information is true and complete to the best of my knowledge. I understand this information is used to determine my eligibility for treatment, and I agree to notify Hydra Mobile Spa of any changes to my health.
Treatment Provider and Medical Director will sign at the time of service.
Your medical history has been received. Our licensed provider will review it before your visit.