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?*

YesNo
Please provide sun detail:

Tanning SalonSunbathe OccasionallySunbathe FrequentlyWork in the Sun
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):

Forehead lines, elevens or crows feetBrow asymmetryFacial wrinkles, fine lines, loose or thin skinDark or sunken under eye areaSmokers' LinesLipsWeak ChinJowlsDouble Chin or Submental FatAppearance of aging in neckAppearance of aging on handsLoose skin on arms or above kneesStubborn abdominal or thigh fatMale or Female Hair RestorationExcessive face, leg or body hairAre the current skin products in my cabinet right for me?Large pores or skin texture issuesAcne (active and/or scarring)MelasmaAge / Brown / Sun spots on skinRed spots / skin vascularityVaricose VeinsVaginal DrynessAge related or Post Childbirth IncontinenceImmune system and vitamin deficiency issuesScar discoloration and/or textureBrow shape, loss color or fadingShort, thin or brittle eyelashes
MEDICAL HISTORY
Are you currently under the care of a physician*

YesNo
If yes, please provide detail:
Do you have any of the following medical conditions? (check any that apply)*

NOT APPLICABLECancerDiabetesHigh Blood PressureHerpesArthritisFrequent cold soresHIV/AIDSKeloid ScarringSkin disease / skin lessionsSeizure disorderHepatitisHormone imbalanceThryroid imbalanceBlood clotting abnormalitiesAny active infectionOther
Please provide any medical condition details:
Have you ever had an allergic reaction? (List any that you have had and describe the reaction)*

NOT APPLICABLEFoodAnimal ProteinAspirinLidocaineHydrocortisoneHydroquinone or skin bleaching agentsOther
If yes to any allergies, please describe the reaction
MEDICATIONS
What oral prescription medications are you presently taking?*

NOT APPLICABLEBirth controlHormonesHeart ConditionAntibioticsAnti-depression or mood stabiliersOther
Please provide detail on all oral prescriptions:
What topical medications or creams are you currently using? (required)*

NOT APPLICABLERetinAOther
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?*

YesNo
Are you pregnant or trying to become pregnant?

YesNo
Are you breastfeeding?

YesNo
Are you using contraception?

YesNo
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):*

Clear
Date

MonthDayYear
Date
Medical Director Signature:

Clear
Should be Empty:

CLIENT INFORMATION & MEDICAL HISTORY

PERSONAL DETAILS

MEDICAL HISTORY

MEDICATIONS

SIGNATURE & ACKNOWLEDGEMENT