DERMAPLANE MEDICAL INTAKE
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Emergency Contact Name and Phone
Primary Physician
Do we have permission to show your photos for educational purposes?
How would you describe your skin?
Oily
Dry
Combination
Sensitive
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?
no scar
red
brown(post-inflammatory pigmentation)
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:
cleanser
toner
serum
scrub
mask
eye cream
moisturizer
sunscreen
self tanner
concealer
makeup
Other
Anything else we should know:
The answers I have provided are true and correct to the best of my knowledge.
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: