VIRTUAL SKIN CONSULTATION INTAKE FORM

CLIENT INFORMATION & MEDICAL HISTORY

AtHomeSkin.com by Beauty Marx
In order to provide you with the most appropriate treatment*, please complete the following questionnaire. All information is strictly confidential.

*All medical treatments provided by Beauty Marx Medical Group PLLC
PERSONAL DETAILS
Name

First NameLast Name
Email for Videoconferencing (FaceTime, Skype, etc)
example@example.com
Mobile Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Age (on appointment date)
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Ship To Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Do you regularly sunbathe, use tanning salons or work in the sun?
Please provide sun detail:
How did you find us?
Who may we thank for your referral

First NameLast Name
Here today for?
(treatment and/or condition)
Other conditions of interest (check any that apply):
MEDICAL HISTORY
Are you currently under the care of a physician
If yes, please provide detail:
Do you have any of the following medical conditions? (check any that apply)

Other
Please provide any medical condition details:
Have you ever had an allergic reaction? (List any that you have had and describe the reaction)

Other
If yes to any allergies, please describe the reaction
MEDICATIONS
What oral prescription medications are you presently taking?

Other
Please provide detail on all oral prescriptions:
What topical medications or creams are you currently using? (required)

Other
Please provide detail on topical medications:
What antibiotics do you use to treat infections?
Please list any herbal supplements you use regularly:
Were you born female?
Are you pregnant or trying to become pregnant?
Are you breastfeeding?
Are you using contraception?
SIGNATURE & ACKNOWLEDGEMENT
I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor, nurse, medical assistants or other staff of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
Today's Date

MonthDayYear
Date
Client Signature & Acknowledgement (use mouse or touchscreen):
Date

MonthDayYear
Date
Medical Director Signature:
Should be Empty:

CLIENT INFORMATION & MEDICAL HISTORY

PERSONAL DETAILS

MEDICAL HISTORY

MEDICATIONS

SIGNATURE & ACKNOWLEDGEMENT