Patient Information
Name: *
Date:
Birthdate:
Address:
City:
State:
Zip:
Daytime Phone: *
Evening Phone:
Email Address: *
Referred By:

Medical History

Have you ever had the following:
Diabetes
Bleeding Disorder
Cancer
Lupus
Rosacea
Sun Sensitivity
Menopause
Cold Sores
Keloid Scar Formation
 
Allergies (please list)
 

Medications / Medical Treatment

Are you currently taking birth control pills? Yes
Are you currently pregnant or lactating? Yes
Have you ever taken Accutane? Yes
Please list all medications you are taking, including all herbal preparations:
Are you presently under a physician's care for any condition? If so, please describe:

Lifestyle Information

Do you consume alcohol? Yes
Do you smoke? Yes
Do you exercise regularly? Yes
Do you use tanning booths? Yes
Describe your history of sun exposure:

Skin Type

Sunburn Easily
Oily
Sunburn, then Tan
Normal
Usually Tan
Dry
Always Tan
Sensitive

Cosmetic History

Filler product injections
BOTOX® Cosmetic injections
Chemical peels in the past year
Laser Treatment

Skin Care History

Please indicate, by brand name, the products you use for daily skin care:

Consultation Information:

What conditions currently apply to your skin?
Uneven skin tone
Enlarged pores
Hyperpigmentation
Lip lines
Acne/ Acne Scars
Age spots
Facial Hair
Fine lines/Wrinkles
Facial capillaries
Loss of Volume
Sagging Skin
 
 

Personal Comments

What would you like to achieve with your treatment(s) and/or skin care recommendations?
We hereby advise you, that to prevent the occurrence of undetected skin cancer, you must have a yearly skin evaluation by a dermatologist
 
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