Health History Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home/Cell Phone *

(###)

###

####

How should we contact you? *

Home/Cell Phone

Email

When is the best time to contact you? *

Morning

Daytime

Evening

Emergency Contact Phone *

(###)

###

####

Do you have any known cancers or metastases?

Yes

No

Do you have a history of epilepsy or seizures? *

Yes

No

Do you use Retin-A®, Accutane® or any other prescribed topical Vitamin A derivative? *

Yes

No

Do you use any medications that cause light sensitivity? *

Yes

No

Are you pregnant or nursing? *

Yes

No

Have you had any recent steriod injections?

Yes

No

Do you currently have any open wounds? *

Yes

No