Pre-Consultation Form
DE NOVO MEDICAL
Name
*
First Name
Last Name
Birth Date
*
-
Day
-
Month
Year
Date
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
Website / Online Search
Referral
Facebook
Instagram
Other
If referral, please list name
Have you ever had a facial or skin treatment before?
*
Yes
No
If yes, when?
Have you been under the care of a dermatologist?
*
Yes
No
If yes, please provide more information
Do you have any permanent cosmetics or tattoos on the areas being treated?
*
Yes
No
If yes, please list area(s)
Have you ever had any injectable aesthetic treatments eg fillers, botox, skin boosters?
*
Yes
No
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?
Hyperpigmentation
Hypopigmentation
What conditions would you like to improve?
*
Acne
Oily Skin
Dry Skin
Occasional pimples
Large Pores
Redness
Brown Spots
Sun Damage
Melasma (hormonal pigmentation eg during pregnancy)
Milia (white spots)
Sagging Skin
Rosacea (flushing to the cheeks or nose)
Lines & Wrinkles
Age Management
Acne Scarring
Hyperpigmentation
Hypopigmentation
Sensitivity
Other
How would you describe your skin?
*
White, very pale, never tans, always burns
White, fair, burns easily, tans poorly
White but darker, tans but may burn initially
Light brown, tans easily, may rarely burn
Medium brown, tans darkly, extremely rarely burns
Dark brown/black, always tans darkly, never burns
What skin care products do you currently use?
*
Rows
Check if you are using a product
Brand name
Timing (choose which)
Cleanser / Face Wash
Morning
Evening
Both
Bar Soap
Morning
Evening
Both
Face Scrub / Exfoliants
Morning
Evening
Both
Toner
Morning
Evening
Both
Serums
Morning
Evening
Both
Moisturizer
Morning
Evening
Both
Sunscreen
Morning
Evening
Both
Retinol
Morning
Evening
Both
Vitamin C
Morning
Evening
Both
Eye Product(s)
Morning
Evening
Both
Lip Product(s)
Morning
Evening
Both
Any additional
Morning
Evening
Both
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
*
Yes
No
If yes, please provide details
Are you taking any other medication, either over the counter or via prescription. This includes contraception
*
Yes
No
If yes, please provide details
Do you have any allergies?
*
Yes
No
If yes, please provide detail
Please provide details of any medical conditions. If none, please confirm by typing 'none'
*
Are you:
*
Pregnant
Trying to conceive
Lactating/breastfeeding
None 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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Please feel free to add any additional comments or questions here
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-
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