DERMAPLANE MEDICAL INTAKE
Street Address Line 2
State / Province
Postal / Zip Code
Emergency Contact Name and Phone
Do we have permission to show your photos for educational purposes?
How would you describe your skin?
Do you feel your stress level may be affecting the health of your skin?
Are you in good health overall?
If no, Concerns
Are you currently under the care of a physician? If yes, please explain
Do you have any allergies to foods or medications? If yes, please explain
Are you currently on any medications either topical or oral? If yes, please explain
Ethnic Background (Parents, Grandparents and Great Grandparents):
How do you heal after an acne breakout, cut or scratch?
Do you Smoke?
Are you prone to cold sores? If so, date of last cold Sore:
Do you tan in the sun or in tanning beds/booths?
Please check the skincare products you are currently using:
Anything else we should know:
The answers I have provided are true and correct to the best of my knowledge.
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform