Medical Intake Form

Medical Intake Form
First name
Last name
Birthdate

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Address

Address

City/St/Zip

City/St/ZipState / Province

Postal / Zip Code
Height
Weight
Allergies to medications
Cell Phone
Home Phone
E Mail
example@example.com
Occupation
How did you hear about us?
Please check all Medical Conditions you have:

Other
List all current medications and those taken in the past 6 months including: Birth Control, Aspirin or ibuprofen, Weight loss medication, Coumadin, or any blood thinning medication, prescription eye drops, steroids, or antibiotics
List all surgeries you have had (including plastic surgery):
Date

MonthDayYear
Date
Surgery
Date

MonthDayYear
Date
Surgery
Date

MonthDayYear
Date
Surgery
Have you ever seen a dermatologist for your skin?
Reason?
Are you pregnant or lactating?
How many months?
Have you ever taken Accutane?
When?
Do you have a history of cold sores?
Last outbreak?
Do you have a history of developing Keloids?
Describe
Do you have regular periods?
Do you smoke cigarettes or use tobacco products?
How often?
Do you use recreational drugs?
How often?
Do you drink alcohol?
How often?
Do you have:

Other
Have you ever been diagnosed with cancer?
What kind and when?
What topical medications do you use? (Retin A, Salicylic Acid, Glycolic Acid, Benzoyl Peroxide, Antibiotics)
What vitamins or supplements are you currently taking?
List all current skin care products
I am aware of the 48 hour cancellation policy. There will be a $50 cahrge per hour or portion thereof, for any treatment not cancelled at least 48 hours in advance.

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Signature:
Date:

MonthDayYear
Should be Empty: