Medical Form

First Name

Last Name

Phone

Please list previous surgeries and aesthetic procedures, including dates:

Please list all medications you are currently taking (including aspirin and any NSAIDS):

Please list all vitamins and nutritional supplements you are currently taking:

List all Allergies:

Do you regularly sunbathe, use tanning booths, or apply tanning creams?

Yes

If yes, when was the last time you did any of the above?

Have you ever had dermabrasion or chemical peel?

Yes

If yes, when was the last time you had one of these treatments?

Are you currently using, or have you ever used Retin-A?

Yes

If yes, when did you start? When did you stop?

Are you currently using, or have you ever used Accutane?

Yes

If yes, when did you start? When did you stop?

Do you have any skin conditions?

Yes

If yes, please specify.

Do you have, or have ever had vitligo (loss of skin pigment)?

Yes

If yes, how has it been treated?

Do you ever get cold sores, canker sores, or herpes eruptions?

Yes

If yes, how has the condition been treated?

Do you form keloids (extra large/prominent scars)?

Yes

Do you currently smoke?

Yes

If yes, how many packs per day? How many years?

Do you drink alcohol?

Yes

Are you pregnant or planning to become pregnant?

Yes

Are you currently breastfeeding?

Yes

What is the main reason for your visit today?

Are there any specific questions you would like to have answered during your initial visit?

Limitation Of Treatment-Please understand that our practice is strictly limited to cosmetic procedures. You understand and acknowledge that we do not examine or treat you for malignancy (cancer) or non-cosmetic skin abnormalities. Skin cancer is an extremely serious (potentially fatal) condition and must be treated immediately. You should be examined on a regular basis by a dermatologist, and you should bring any concerns regarding skin changes or skin cancer to the attention of a dermatologist immediately. Please type the date and your full name down below.

I declare that the info I’ve provided is accurate & complete

Medical Form

Book appointment today