Consent Form /Medical History Permanentlyyou

How do you react to the Sun?

Sun Exposure?

Ocasional Occupational recreational

Do you use tanning beds?

Yes No

If, yes, How often?

Weekly Monthly Several times a week A few times per year

Do you use self tanner?

Yes No

Do you use sun protection?

Yes No

When were you last exposed to the sun?

Less than a week 2 weeks 1 month

COSMETIC MEDICAL HISTORY

Are you under the care of a Dermatologist?

Yes No

If Yes, reason for treatment?

Do you currently use, or are currently taking, this medications?

Have you had plastic surgery

Yes No

If Yes, which Procedure

Have you had Cosmetics injections?

Yes No

have you had any of the following Cosmetics treatments (check all that apply)

GENERAL MEDICAL HISTORY

Do you have or ever had Skin Cancer?

Yes No

Please list all current medications:

Please list all relevant surgeries and when

Please check all that apply

Have you had childrens?

Yes No

How would you rate your stress level

High Moderate Low

On average how much sleep you get per night?

More than 8 hours 6-8 hours Less than 6 hours

How would you rate your diet?

Healthy Poor Vegetarian/Vegan Restricted

How would you rate your diet?

How much of the Following you have each day?

How often do you exercise?

Less than 2 days a week 3 days a week More than 5 days a week

Please Check, I Agree

A complete and accurate medical history is important to ensure that it is safe for you to receive treatment and to determine the most beneficial treatment and products. Treatment protocol is based solely on the information provided. By pressing SUBMIT, you understand that the information you have provided above is to the best of your knowledge and will be kept confidential exclusively by Permanentlyyou.

Phones (647) 400-8069 & (289) 400-0702

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