Medical History

"(*Required)" indicates required fields

Address(*Required)

PERSONAL INFORMATION

Alcohol(*Required)
Tabacco(*Required)
Drugs(*Required)
Would you like to be put on our mailing list to receive beauty tips and updates from the clinic?
Email(*Required)
Text Message(*Required)

MEDICAL HISTORY

CHECK YES/NO FOR EACH CURRENT OR PAST CONDITION

Bleeding disorders(*Required)
Heart conditions(*Required)
High blood pressure(*Required)
Diabetes(*Required)
Cancer(*Required)
Thyroid(*Required)
Nervous system disorders(*Required)
Lung disorders(*Required)
Blood-borne infections (Hep C, HIV)(*Required)
Book Now
Book Now
PHONE US
514-613-2979
Email Us
Find Us