Name* First Last Date*Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Main Phone Number*Secondary Phone NumberEmail* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How did you hear about Coral Spa?*Describe the nature of your visit?*What are your expectations?*Please select any past or present health issues that you are experiencing or have experienced?* None of these apply Heart Condition Keloids Scarring Permanent Makeup/Tattoos Cold Sores/Herpes Pacemaker LupusDiabetes Type 1 or 2 Epilepsy Pregnant/Lactating Are you currently pregnant?*YesNoAre you breastfeeding?*YesNoIf yes, what is your Due Date?Medications* Blood Thinners Antibiotics (past 2 weeks) Accutane (past 6 months) Sun-Sensitive Medications Other If you selected "yes" or "other" to any of the medications above, please indicate which medication & dosingDo you have any allergies?SKINCAREDo you have a history of breakouts?*YesNoIf so, what is the frequency of your breakouts?FrequentOccasionalRarelyDo you experience cystic breakouts?*YesNoDo you have any scarring as a result from your acne?*YesNoSkin BackgroundHave you had prolonged sun exposure (or tanning bed) in the past 3 days?*YesNoIf so, are you currently sunburned?YesNoDo you use tanning beds?*YesNoAre you using chemical tanning solutions?*YesNoDo you use sunscreen on a regular base?*YesNoFitzpatrick I-VI(I) Always burns, never tans(II) Usually burns, tans less than average(III) Sometimes mild burn, tans about average(IV) Rarely burns, tans more than average(V) Rarely burns, tans profusely(VI) Never burns, deeply pigmentedSelect one (when exposed to the sun without protection for approximately 1 hour):Skin Type*CaucasianHispanicMediterraneanAfrican AmericanAmerican IndianOtherCheck one (when exposed to the sun without protection for approximately 1 hour):Are you currently tanned?*YesNoHave you waxed, used depilatories, bleaches or other chemical processes?*YesNoHow much water do you normally consume daily?* Do you exercise?*YesNoDo you smoke?*YesNoHave you had microdermabrasion?*YesNoHave you had any chemical peels?*YesNoHave you had laser resurfacing?*YesNoDo you have rosacea?*YesNoDo you have wrinkle concerns?*YesNoDo you have scarring concerns?*YesNoDo you have sun damage concerns?*YesNoDo you have pigmentation concerns?*YesNoDo you have broken capillary concerns?*YesNoHave you had Botox or Collagen injections in the past 6 months?*YesNoIf yes and less then 3 months, approximate dates? Do you use:* Topical Ointments Retin-A Glycolic Lactic Acid Hydroquinone Other Which skincare brand do you use?*Check other services of interest:* Laser Hair Removal Laser Vein Removal Non-ablative LaserFACIAL Pigmented Lesions or Brown Spot Removal Other If you selected Laser Hair Removal, which area's?If you selected Other, please specifyI understand that ANY type of sexual harassment/misconduct is absolutely forbidden. This is defined but not limited to the exposure of any body parts in the “bikini area” (unless I am doing a Brazilian/Bikini treatment), inappropriate touching, sexual innuendo’s, aggressive come-ons, comments about my providers physical appearance or comments which would make my provider fearful or uncomfortable. I also understand that failure to adhere to this policy will result in a lifelong ban from the facility. I certify that the above medical history information is accurate and correctConsent* I have read everything above and understand it. I consent to to allow Signature
