Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile *

(###)

###

####

May We Contact You Via Email? *

Yes

No

Date of Birth *

MM

DD

YYYY

Please check any of the following that you have presently or have had previously: *

Pacemaker

Internal Defibrillator or Electronic Implant

Skin Disorder

Excessive Tan/Use of Topical Tanning Lotion

Keloid Scarring

Abnormal Wound Healing

Dry/Fragile Skin

Thyroid Dysfunction

Hypertension

Agina / Chest Pain

Arrhythmia

CHF

MI (Heart Attack)

Abnormal EKG

Kidney Disease

Blood / Bleeding Disorder

Sudden Weight Loss

Diabetes

Anxiety / Panic Attack

G6PD

Lebers Disease

Liver Disease

Current / History of Cancer (*Especially Skin Cancer, Pre-Malignant Moles)

None of the Above

Check if you have been treated with the following: *

Botox in Last 2 Weeks

Retinoids in Last 2 Weeks

Isotretinoin (Accutane) in Last 6 Months

Permanent Implant in Treated Area (*Metal Plates and Screws, Silicone Implants or Injected Chemical Substance)

Active Condition in Treatment Area (Sores, Pscoriasis, Eczema, Rash and Excessive/Recently Tanned Skin)

None of the Above

If you were previously treated with Botox / Hyaluronic Acid Fillers, please note the last treatment date:

MM

DD

YYYY

Do You Have A Gold Sensitivity? *

Yes

No

Do you smoke? *

Yes

No

Do you drink alcohol? *

Yes

No