Heath History Form - Layers Wellness & Spa

Name*

First Last

Email*

Enter Email Confirm Email

Address

Street Address Address Line 2 City Province Postal Code

Have you ever had any of the following?

Are you taking any medications and/or herbs that are photosensitive or that may cause a sensitivity to light exposure? Examples are isotretinoin, tetracycline or St. John’s Wart.

Yes
No

Are you presently taking any of the following?

Birth control
Hormones
Aspirin
Anti-coagulants
Anti-biotics
Insulin
High blood pressure drugs
Other

Please list other medications*

Please list your allergies*

What forms of hair removal have you used in the past?

Skin Type*

Have you recently used any self-tanning lotions or treatments?*

Yes
No

Reason for your visit today?*

Consent*

I agree to the privacy policy.

I certify that the preceding medical, personal and skin history are true and correct. I also am aware that if anything changes in my health history I am responsible for keeping my technician or esthetician up to date on my health conditions.

Health History Form

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