PATIENT INFORMATION
Name:____________________________________
DOB:____________ Age:_______ Sex: M / F
Address:____________________________________________________________________ญญ
City:
Work Phone:____________________________
Home Phone:____________________________
Cell Phone:_______________________
Referred by:___________________________________
E Mail Address:__________________________________________________________________
In case of Emergency contact:
______________________________Phone:____________________
Occupation:_________________________________
Height:___________ Weight:_________
Are you basically in good health? (circle one) Yes No
Has there been any change to your
health in the past year? (circle one) Yes
No
If yes, please explain:__________________________________________________________
Ethnic Background:___________________________________________________________
After 4+ hours in the sun
with no sunblock, my skin will: (check one)
Severely burn,
blister, peel
Burn, no
blister, light tan
Burn first, tan
in 2 days
Pink first, then
tan
Never burn, just
tan
Just get darker
Too dark to tell
My skin is:
Dry
Oily
Combo normal/dry
Combo
normal/oily
Acne
Medical Information
Do any of the following
pertain to you? (Check if yes)
Accutane/Retin A/Renova
Allergies
Aspirin,
Ibuprofen
Facial laser
resurfacing/deep chemical peeling in the last 3 months
Pacemaker/defibrillator
Metal implants
Current or
history of skin cancer/other cancer/pre-malignant moles
Autoimmune
disease, HIV, Lupus, Hepatitis
Birth control
pills, hormone therapy
Bruise easily,
cuts
Diabetes
Eczema/Seborrhea/Psoriasis
Herpes, cold
sores, fever blisters
Keloids,
pigmented scars
Irregular,
pigmented moles or growths
Pregnancy,
breast feeding
Stretch marks
Sunburn
Warts
Alcohol
Smoke
List ingested and topical
medications you are taking:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list any allergies
(medications, foods etc.):
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please take a moment to
carefully read the information you have provided and sign where indicated. If you have a specific medical condition or
specific symptoms, certain esthetic treatment may be contraindicated. A referral from your primary care provider
may be required prior to service being rendered.
Patient Signature: _____________________________________________ Date:
_______________
Clinician Signature: ________________________________________________________________