Are there any updates to your medications?
Yes____       No____

If yes, please list all medication changes.

Have you used antibiotics recently?
Yes____       No____

If yes, was your last dose within the last 2 weeks?

Do you have any changes to your health history since your last appointment?
Yes____       No____

If yes, please list changes to your health history since your last appointment.

Have you used any new topical applications to the area of treatment within the last 7 days?
Yes____       No____

If yes, please list new topical applications to the area of treatment within the last 7 days.

Are you currently tan or have you had concentrated sun exposure in the desired treatment areas in last 2 weeks?
Yes____       No____

If yes, let’s postpone your upcoming treatment.

Do you currently have residual self tanner that is not fully faded in the area of treatment?
Yes____       No____

If yes, let’s postpone your upcoming treatment.

Have you experienced any of the following symptoms in the past 48 hours:
• fever or chills
• cough
• shortness of breath or difficulty breathing
• fatigue
• muscle or body aches
• headache
• new loss of taste or smell
• sore throat
• congestion or runny nose
• nausea or vomiting
• diarrhea
Yes____       No____

If yes, let’s postpone your upcoming treatment.

Are you feeling sick right now at all? 
Yes____       No____

If yes, let’s postpone your upcoming treatment.

In the last 10 days, did you care for or have close contact (within 6 feet of an infected person for at least 15 minutes) with someone with symptoms of COVID-19 or known to have COVID-19?
Yes____        No____

If yes, have you had a negative Covid test within the last 5 days, 5 days after your exposure?
Yes____        No____

If no, let’s postpone your upcoming treatment.

Would you like your technician to wear a mask?

Yes____        No____