Medical Form

First Name

Last Name

Email

Phone

Do you have or have you ever had any of the following? Please check all that apply:

Allergies

Arthritis/Joint Problems

Back Problems

Cancer

Chemical Dependency

Depression

Epilepsy

Heart Problems

Hepatitis/Liver Disease

HIV/AIDS

Mitral Valve Prolapse

Prostate Problems

Radiation Treatment

Respiratory Disease

Stroke

Thyroid Problems

Venereal Disease

Anxiety Disorder

Autoimmune Disorder

Blood Disease

Circulatory Problems

Diabetes

Headaches

Hemophilia/Bleeding Disorder

High Blood Pressure

Joint Prosthesis

Pacemaker

Psychiatric Care

Recent Weight Loss

Sinus Problem

Swollen Neck Glands

Ucler Disease

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:

Have you ever had a reaction to any of the following? Please check all that apply:

Iodine

Seafood

Collagen injections

Porcine (pig) products

Hyaluronic acid injections

Any dermal fillers

Any local anesthetic

Eggs/albumin

None

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

Yes

No

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

Have you ever had dermabrasion or chemical peel?

Yes

No

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

No

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

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

Yes

No

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

Do you have any skin conditions?

Yes

No

If yes, please specify.

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

Yes

No

If yes, how has it been treated?

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

Yes

No

If yes, how has the condition been treated?

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

Yes

No

Do you currently smoke?

Yes

No

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

Do you drink alcohol?

Yes

No

Are you pregnant or planning to become pregnant?

Yes

No

Are you currently breastfeeding?

Yes

No

What is the main reason for your visit today?

Please select all areas of concern that are relevant to you.

Fine lines and wrinkles

Lines around nose and mouth

Skin texture

Uneven skin tone

Dark circles or bags under eyes

Acne

Scars/acne scars

Brown/red/purple discolorations

Spider veins

Hands (loss of volume)

Sun damage

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

Your Signature

Medical Form

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