Welcome to Milani MedSpa. For your convenience, please print and fill out all applicable forms and present them to the front desk when you arrive for your first office visit.

Personal Information:

  • - How Did You Hear About Us? -
  • Clinic Referral
  • Facebook
  • Instagram
  • Website / Google
  • Papers Ad
  • Word of Mouth
  • Referrals
  • Others

Contact Information:

  • - Preferred Method of Contact -
  • Home Number
  • Cell Number
  • Email

Emergency Contact Information:

Surgical History

Do you have any medical problem or serious illnesses?

Medical History:

Do you have a Pacemaker?
Do you have a Defibrillator?
Do you suffer from “Photosensitivity” (extreme sensitivity to sunlight)?
Do you have a history of easy / excessive Hyperpigmentation?
Do you form keloid scars?
Do you suffer from seizures?
Do you have any metal implants?
Have you taken Accutane Retin A in the past 12 months?
Have you taken Renova in the past 12 months?
Are you currently taking Coumadin (Warfarin) or other blood thinners?
Do you smoke?
Do you drink Alcohol?
Have you ever had an adverse reaction to laser or cosmetic treatments?
Are you allergic to any medication?
Do you have any other allergies?
Do you have any of the following? (Please check all that apply and/ or list additional medications)
Are you taking herbal preparations or vitamins?
Are you pregnant?
Are you planning on becoming pregnant?
Are you nursing?
Have you had or do you have any of the following conditions? (Check all that apply):

Skin Care and Concerns:

Have you had unprotected sun exposure or have been in a tanning booth in the past 2 weeks?
Are you planning a vacation in the sun in the next 3-6 months?
Do you use self-tanners?
Have you used any of the following hair removal methods in the past 6 months?