PATIENT INFORMATION

Name:____________________________________ DOB:____________ Age:_______ Sex: M / F

Address:____________________________________________________________________

City:__________________________________________ State:__________ Zip:_____________

Work Phone:____________________________ Home Phone:____________________________

Cell Phone:_______________________ Referred by:___________________________________

E Mail Address:__________________________________________________________________

In case of Emergency contact: ______________________________Phone:____________________

General and Medical Information

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:__________________________________________________________

Are you interested in a skin care program? (circle one) Yes No

Ethnic Background:___________________________________________________________

Physician: _______________________________ Telephone: ________________________

WHAT ARE YOUR SPECIFIC SKIN CARE CONCERNS
Please note an “X” the area where the skin condition concern can be found.
	Face	Body		Face	Body
Age/Sun Spots			Oily Skin
Blackheads			Sensitive Skin
Breakouts			Dry Callused elbows/knees
Capillaries, visible			Small, dry bumps
Dehydration			Puffy, spongy skin
Dry, flaky skin			Overall loss of tone
Fine line/wrinkles			Acne on back chest

Have you had any of the following? € Yes € No (please check all that apply)

€ Cosmetic Surgery € Botox Injections € Glycolic Acid Peel € Skin Cancer

€ Laser Resurfacing € Chemical Peels € Microdermabrasion € Keloid Scarring

€ Dermatitis € Hepatitis € Other (specify):__________________

Do you currently use any of the following: € Yes € No (Please check all that apply)

€ Accutane € Glycolic Acid/AHA € Topical Vitamin C € Sunscreen/ Sun Block

€ Hydroquinone € Retinoid (Vitamin A derivatives) i.e. Retin A, Renova, Differin

HOW YOU CARE FOR YOUR SKIN
How much time do you spend caring for your skin each day:					Less than 5 mins.		5 to 15 mins.		Over 15 mins.
WHAT DO YOU DO TO CARE FOR YOUR SKIN		Mark “X” in the column that most closely describes your regimen
	Brands & Type of Product(s) You Use		Morning & Night	Only Morning		Only Nighttime		On Occasion		Never
Cleanser
Toner
Exfoliant
Mask
Moisturizer
Sun Protection (SPF?)
Eye Care
Foundation
Other

LIFESTYLE AND ENVIRONMENT
Has your skin been different lately- If so, list anything you are now doing or changing in your lifestyle.
Suffer from Premenstrual Breakouts	Yes	No			√=Yes
				Currently under Care of:
Usual Stress Level	Low	Moderate	High	Cosmetic Surgeon
Physical Activity Level	Low	Moderate	High	Dermatologist
				Endocrinologist
				Homeopath
DIET-Describe your normal diet				Nutrition
Fats	Low	Moderate	High	Medical Doctor-Type___________
Starch	Low	Moderate	High	Other Type___________________
Sugar	Low	Moderate	High	Pregnant – what trimester
Alcohol	Low	Moderate	High	Undergoing Menopause
Tobacco	Low	Moderate	High	Undergoing Puberty

LIST MEDICATION PRESENTLY USING (Including Antibiotic, Antihistamines, Hormones or Birth Control Pills)
Medication or Brand	Reason or Purpose

LIST ALL VITAMINS OR FOOD SUPPLEMENTS
Vitamin or Brand Name	Purpose

Is diabetes or heart disease an area of concern for you? € Yes € No

Is osteoporosis a particular area of concern for you? € Yes € No

INDICATE ALL ACNE MEDICATED USING	√=Yes	FAMLY MEMBERS WHO EXPERIENCE ACNE	Age at
Benzoyl Peroxide_____% Brand Name_________			Onset	End
Retin-A (Tretinoin)_____% Cream Gel Lotion
Accutane (Isotretinoin)
Erythromycin
Tetracycline
Other:

SUPPLEMENTAL ACNE INFORMATION			OTHER COSMETICS USED ON OR NEAR FACE
Age at onset of acne				Brand Name	Description/Comments
Are you Allergic to Benzoyl Peroxide?	Yes	No	FOUNDATION
Are you Allergic to Sulfur?	Yes	No
Use a hot tub or sauna frequently	Yes	No	BLUSH
Work around chemicals, tars, oils, or inks	Yes	No
Use fabric softener	Yes	No	HAIR PRODUCTS
Regularly ingest – Kelp	Yes	No
Seaweed	Yes	No
Sea Salt	Yes	No

MEDICAL HISTORY
Back Pain	Eczema	Menstrual Problems or PMS
Blood Pressure-High	Fatigue – chronic	Metabolic/Digestive Disorders
Blood Pressure-Low	Hay Fever	Nail Fungus
Cancer – any kind	Hemophilia	Pacemaker
Claustrophobia	Hepatitis	Prosthesis
Constipation – at present	Hormone Imbalance	Teeth-removable or dentures
Hypoglycemia/low blood sugar	Dermatitis	Thyroid problems
Eye-wear contacts lens	Psoriasis	Infectious or Contagious-Now
Health or Circulatory Problems	Varicose Veins
Acne	Diabetes

List all allergies to medications, foods, etc.:

Please circle the following procedures you are interested in:

Abdominoplasty (Tummy Tuck)	Arm Lift	Blepharoplasty (Eye Lids)
Augmentation (Breast Implants)	Breast Reduction	Liposuction
Face/Neck Lift	Forehead/Brow	Permanent Make-Up
Mastopexy (Breast Lift)	Rhinoplasty (Nose)	Laser Hair Removal
Thigh Lift	Botox	IPL Fotofacial
Cellulite Reduction Treatment	Collagen/Juvederm Injections	ReFirme Skin Tightening

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 treatments may be contraindicated. A referral from your primary care provider may be required prior to service being rendered.

Patient Signature:____________________________________________________ Date:________________

Clinician Signature:________________________________________________________________________

PATIENT POLICIES

Skin Care is an important part of everyone’s daily life. We at the Alvarado Institute of Skin Care are here to serve our patients and all of their skin care needs. We will try our best to meet your goals.

1. All patients must render payment at the time of service.

2. If you are scheduled for two or more services and find you must cancel your appointment, please do so 48 hours prior to your appointment. If you have made an appointment for a single service and must cancel it, please do so 24 hours prior to your appointment. This cancellation policy provides our staff the opportunity to reschedule other patients who are on a waiting list into your previously held appointment time. The staff works by appointment only and it is important for them to keep their appointment books full. Failure to cancel an appointment within the required amount of time will result in a $60 charge for scheduled services. If you have a gift voucher for the services, you will be charged the standard $60 fee and the voucher will be voided. If your appointment is a pre-paid service, you will have the option to pay the cancellation fee or lose one treatment off your existing package.

3. No exceptions to these policies will be made.

4. We prefer that our patients do not bring children with them to their visits, as this is a time of relaxation for all our patients. Of course, we realize that a sitter is not always available. Please notify us in advance when your children will be present.

5. We have gift certificates available. If you know you would like to purchase one, please let us know before your appointment and we will be glad to gift wrap it for you.

6. There is a $20.00 charge on all returned checks as well as the banks fees. No exceptions will be made.

7. Packages are not refundable under any circumstances but may be transferred to other packages of services. Packages are not transferable to product purchases.

8. For the consideration of others, please turn all cellular phones and pagers to silent mode during the time of your appointment.

9. Patient Referral Program: We believe in giving back to our patients and do so by providing you with 20% off your entire next product purchase or ½ off of a off a medical skin care treatment of your choice for the referral of one friend or family member. Please see the front desk for further details.

Patient Signature:_______________________________________________________ Date:___________________

Witness Signature:______________________________________________________ Date:___________________

Alvarado Institute of Skin Care

5565 Grossmont Center Drive

Building 1, Suite 126

La Mesa, CA 91942

(619) 286-0372

instituteofskincare@yahoo.com