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CLIENT PROFILE
Fullname *
Date of Birthdate * Email *
Age Gender *

Home Phone Mobile
Occupation Nationality *
How did you hear about us? *
Which Cocoon Wellness/Medical spa are you now? *
Have you ever had cosmetic procedures before?

MEDICAL HISTORY
MEDICATIONS ALLERGIES
COSMETIC ALLERGIES INGREDIENT
List All Prescription and Over the Counter Medications You are Currently Taking (Including Asprin, Ibuprofen,Herbs& Vitamin):
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Pre- Treatment Medical Questionnaire
Do you have Yes No Comments
Known Allergies
Heart problems
High Blood Pressure
Diabetes
Stroke
Bell's palsy (or other facial weakness)
Liver or Kidney disease
Asthma
Keloid
Skin problems e.g. Herpes (cold sores), acne, psoriasis, dermatitis, eczema
Blood disorders e.g. Bleed or bruise easily
Current infection or illness
Recent surgery (incl dental work)
Drug Treatment/ Medication (current or recent)
Any previous cosmetic, injectable treatments. If so, when, where, which product, any adverse/allergic reaction
Previous Surgery
Pregnant/ Breast Feeding
Do you smoke
Do you drink alcohol