Health History Form

  • MM slash DD slash YYYY
  • Please provide us with the phone number for which you are most easily reached.
  • Your Health

  • Your Skin

  • Hormonal Health

    These questions can help us determine sensitivity to aspects of the treatment or possible contraindications to treatment.
    *Information about potential risks is provided through Collective Skin Care's online booking system.
  • This field is for validation purposes and should be left unchanged.