Client Profile — Arctic Recovery Solution

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Client Profile

Please complete your client profile and submit prior to your booking.

Client Profile

Date *

MM

DD

YYYY

Name *

First Name

Last Name

Email *

Phone *

(###)

###

####

Date of birth *

MM

DD

YYYY

Gender

How did you hear about us?

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Do you have any skin sensitivities or allergies? *

Yes,Please specify

Specify any medical conditions

List any medications that you are taking

Have you had any major surgery performed in last 3 months?

Yes

No

Yes, please specify

Medical Information

Do any of the following apply to you? Please pick those that apply.

Heart Disease

Burns/Grafter skin

Polycustic ovarian syndrome

Hirsutism

Liver/Kidney disease

Port wine stain

Haemangioma

Shingles

Steroid of hormonal therapy

Thyroid hormone deficiency

Diabetes

Aids

Gold injections

Haemophilia

Anti-coagulants

Peripheral vascular disease

Acne

Cancer (or radiation)

Herpes (or cold sores)

Keloid formation/scars

Melanoma/Moles

Epilepsy

Psoriasis

Skim Pigmentation

Vitiligo

Hormonal Imbalance

Lupus

Clotting disorder

Anti-inflammatory

Pregnant

Breast feeding

Peripheral neuropathy

Yes,Please specify

Sign and Date

Please review all information is correct and sign. This e-signature gives your specialist permission to store client profile.

Signature *

Please type your full name

Date

MM

DD

YYYY

Thank you!

Consultation Form

Consultation Form

Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical History *

Areas of concern *

Thank you!

Please complete your client profile and submit prior to your booking.

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Email Address

Thank you!

Stay in touch.

➤ LILLINGTON,NC
(Servicing The Research Triangle, Southern Pines and Fayetteville areas.)

☎ 910-709-3513

✉ Shane@arcticrecoverysolution.com

⌚Mon-Sat: 8:00am - 5:00pm | Sun: closed

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