New Patient Form

Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Email
example@example.com
How did you hear about us?*
Facial Analysis

For an effective and personalized treatment please be as accurate as possible! (Check All That Apply)
NormalDryCombinationOilyBreakoutVery Sensitive/RosaceaAcneMature
Acne Lesions (Cysts)Acne ScarsBlack HeadsEnlarged PoresWhite HeadsHyperpigmentation (brown spots from: sun/scars/hormonal)Papules (Inflamed)Dilated CapillariesIngrown Hairs
Crows Feet/WrinklesPuffinessLack of ElasticityDark Shadows
HyperpigmentationNasolabial FoldsWrinkles
Loss of ElasticityCross Wrinkling (sun damage)HyperpigmentationDilated PoresUneven TextureVisible Capillaries
WrinklesSevere Sun DamageLack of ElasticityHyperpigmentation
How often do you receive facials?
MicrodermabrasionWaxing ServicesAcid PeelsEnzyme Peels
Rhytidectomy (Face Lift)Rhinoplasty (Nose)Blepharoplasty (Eye Lift)Laser ResurfacingMedical Acid PeelsCollagen InjectionsRestylane InjectionsBotox InjectionsMicrodermabrasionOther
Eye Makeup RemoverCleanserTonerMoisturizerExfoliatorMaskMakeupSunscreen
If you could improve one thing about your skin what would it be?
General Health Analysis (Check All That Apply)
CancerHormone ImblalanceSystemic DiseaseHigh Blood PressureSpinal InjuryThyroid ConditionHysterectomyDiabetesHeart ProblemVaricose VeinsArthritisEczemaEpilepsySeizure DisorderFever BlistersHeadaches (chronic)HepatitisHerpesFrequent Cold SoresImmune DisordersHIV/AIDSMetal Bone Pins or PlatesLupusPhlebitis, Blood Clots, Poor CirculationBlood Clotting AbnormalitiesPsychological TreatmentInsomniaKeloid ScarringSkin Disease/Skin LesionsAny Active InfectionOther
YesNo
If yes, please specify:
YesNo
If yes, please specify:
YesNo
If yes, please specify:
YesNo
YesNo
If yes, please describe:
YesNo
If yes, please list which acne medicaion and when?
YesNo
Do you wear contact lenses?
YesNo
InfrequentlyFrequentlyRegularly
YesNo
If yes, please specify:
RashIrritationPeelingSun SensitivityBreakout
CosmeticsMedicineFoodAnimalsSunscreenIodinePollenFragranceShellfishLatexDrugsOther
Female Clients Only
YesNo
If yes, please specify:
YesNo
YesNo
YesNo
If yes, please specify:
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
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Facial Analysis

General Health Analysis (Check All That Apply)