Aesthetic Medical History Form

Name*

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Cell Number *

Please enter a valid phone number.Format: (000) 000-0000.

Ok to Text?*

Email*

example@example.com

Date Of Birth 00/00/00*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Sex*

Family Doctor*

Emergency Contact

First NameLast Name

Emergency Contact's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

How Did you find out about us?

Which body area(s) or conditions would you like treated? Please mark N/A if no. *

Do you have ANY allergies to medications, foods, latex, or other substances? Please list:

Do you Smoke? *

Average per day? If not please mark N/A*

Do you drink alcohol?*

Average per day? If not please mark N/A*

Do you have ANY current or chronic medical conditions?Disclose any history of heat urticaria, diabetes, autoimmune disorder or any immunosuppression, blood disorders, cancer, bacterial or viral infections, medical conditions that significantly compromise the healing response, skin photosensitivity disorders, or any other condition or illness.*

If Yes, Please list, Please mark N/A if no..*

Do you have ANY current or chronic skin conditions?Also disclose any history of vitiligo, eczema, melasma, psoriasis, allergic dermatitis, any diseases affecting collagen including Ehlers-Danlos syndrome, scleroderma, skin cancer, or any other skin condition.*

If Yes, Please list, Please mark N/A if no..*

Are you under a doctor’s care?*

If so, for what? Please mark N/A if no..*

Do you take ANY medications (prescriptions or non-prescriptions) including vitamins and herbal supplements on a regular basis?*

If so, for what? Please mark N/A if no..*

Are there any topical products (both medical and non-medical) that you use on your skin on a regular or daily basis? *

If so, for what? Please mark N/A if no..*

Are you taking oral steroids (eg. prednisone, dexamethasone)? **

Do you have a pacemaker or external defibrillator? **

Do you have any metal implants under the area being treated? **

Do you have a history of light-induced seizures?*

Do you have a history of Herpes in the area being treated? **

Do you have any open sores or lesions? **

Have you had radiation therapy in the area being treated? **

Do you have a history of keloid scaring or hypertrophic scar formation? **

In the last 6 months, have you used any of the following? Anticoagulants or blood-thinning medications, photosensitizing medications or anti-inflammatories?*

List Product, Date Used: Please mark N/A if no. *

In the last 3 months, have you used any of the following products: glycolic acid or other alphahydroxy- or betahydroxyacid products, exfoliating or resurfacing products or treatments?*

If so, for what? Please mark N/A if no.*

Have you had any cosmetic procedures in the past 6 months?*

If so, for what? Please mark N/A if no.*

Have you had any permanent make-up, tattoos, implants, or fillers, including: but not limited to collagen, autologous fat, Restylane, ect.?*

If yes, please list locations and dates, Please mark N/A if no.*

In the last month, have you been treated with any Botulinums (eg. Botox or Dysport)?*

If yes, please list locations and dates, Please mark N/A if no.*

Have you taken Accutane (or products containing isotretinoin) or Tretinoin (eg. Retin-A, Renova) in the last 6 months?*

Have you had any unprotected sun exposure, used tanning creams (including sunless tanning lotions) or tanning beds/lamps in the last month?*

Are you pregnant or breastfeeding?*

Are your menstrual periods regular*

Have you been diagnosed with Polycystic Ovarian Disorder?*

Signature*

Aesthetic Medical History Form

Please answer each of the following questions:

For Women Only