HEALTH

SUBMIT HEALTH DECLARATION

Health Declaration

DECLARATION OF GOOD HEALTH FORM

I hereby submit this form to indicate that I have been feeling well and my temperature has been normal. I understand that if I am not feeling well or if I am running a temperature on the day of my appointment, I should contact Permetika to reschedule my appointment. I understand there to be no charge, and no penalty for missing an appointment, once. Thereafter, I will need a doctor's note to reset again.

Are you experiencing any flu-like symptoms?

Yes

Do you have any artificial limbs, joints or a pacemaker? Have you ever had MRSA, Staph, or Shingles? If so, please inform us by selecting yes below and contact your doctor for advice regarding any cosmetic prodedures.

Yes

I confirm that the information given in this form is true.

Entering name constitutes legal and binding signature:

Date

Thanks for submitting!

CLIENT DATA FORM

MEDICAL HISTORY FORM

WELLNESS FORM

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