Pre-consultation Form

Pre-Consultation Form

DE NOVO MEDICAL
Name*

First NameLast Name
Birth Date*

DayMonthYear
Date
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?

Website / Online SearchReferralFacebookInstagramOther
If referral, please list name
Have you ever had a facial or skin treatment before?*

YesNo
If yes, when?
Have you been under the care of a dermatologist?*

YesNo
If yes, please provide more information
Do you have any permanent cosmetics or tattoos on the areas being treated?*

YesNo
If yes, please list area(s)
Have you ever had any injectable aesthetic treatments eg fillers, botox, skin boosters?*

YesNo
If yes, what, where and when
Does your skin form Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?

HyperpigmentationHypopigmentation
What conditions would you like to improve?*

AcneOily SkinDry SkinOccasional pimplesLarge PoresRednessBrown SpotsSun DamageMelasma (hormonal pigmentation eg during pregnancy)Milia (white spots)Sagging SkinRosacea (flushing to the cheeks or nose)Lines & WrinklesAge ManagementAcne ScarringHyperpigmentationHypopigmentationSensitivityOther
How would you describe your skin?*

White, very pale, never tans, always burnsWhite, fair, burns easily, tans poorlyWhite but darker, tans but may burn initiallyLight brown, tans easily, may rarely burnMedium brown, tans darkly, extremely rarely burnsDark brown/black, always tans darkly, never burns

What skin care products do you currently use?*

	Check if you are using a product	Brand name	Timing (choose which)
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Retinol
Vitamin C
Eye Product(s)
Lip Product(s)
Any additional

What are your skin care goals/what would you like us to achieve together?*
Are you using any prescription medication for your skin (topical or oral) eg tretinoin, antibiotics*

YesNo
If yes, please provide details
Are you taking any other medication, either over the counter or via prescription. This includes contraception*

YesNo
If yes, please provide details
Do you have any allergies?*

YesNo
If yes, please provide detail
Please provide details of any medical conditions. If none, please confirm by typing 'none'*
Are you:*

PregnantTrying to conceiveLactating/breastfeedingNone of the above
Please add photos of your skin. Preferably straight on, side on and at 45 degrees on each side

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Pre-Consultation Form