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Services
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Nest Beauty Spa
Medical Information Form
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1. In order for us to better serve you, please answer all the questions provided below. If you required any assistance, please do not hesitate to contact us.
*
First
Last
Address
Apt/Suite
Email
*
Phone
Birthday:
Referred by
2. Please mark all that applies
*
Pregnancy and nursing
Accutane (must discontinue 6 months before)
Antibiotic, Retinoids or other acne medications
Antihistamines
Cancer chemotherapy drugs, radiation therapy
Epilepsy or those who have a history of seizures
Active cold sores or fever blisters(antiviral med)
Skin disorder such as keloids
Pacemaker or any internal metal device
Tattoos in the area to be treated
Bleeding problems or use of blood thinners
HIV/HPV
Multiple sclerosis
Herpes simplex
Tanning (sun exposure/self-tanning products)
Hepatitis
Waxing/plucking (before 4 weeks)
Cystic acne
None of above
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