Aesthetic Medical History Form

Name*

First NameLast Name

Cell Number *

Please enter a valid phone number.Format: (000) 000-0000.

Ok to Text?*

Email*

example@example.com

Date Of Birth 00/00/00*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Sex*

Primary Care Provider*

Emergency Contact

First NameLast Name

Emergency Contact's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

How Did you find out about us?

Which body area(s) would you like treated? *

Do you have ANY allergies to medications, foods, latex, or other substances? Please list or, if none, type NONE:

Do you smoke or use tobacco products? *

Average per day? If none, please mark N/A*

Do you drink alcohol?*

Average per week? If none, please mark N/A*

Do you have ANY current or chronic medical conditions (i.e. high blood pressure, diabetes, heart disease, asthma, thyroid disease, lupus, rheumatoid arthritis, history of heat urticaria, autoimmune disorder or any immunosuppression, blood disorders, cancer, bacterial or viral infections, medical conditions that significantly compromise the healing response, skin photosensitivity disorders, or any other condition or illness)?*

If Yes, Please list, Please mark N/A if no..*

Do you have ANY current or chronic skin conditions (i.e. vitiligo, eczema, melasma, psoriasis, allergic dermatitis, any diseases affecting collagen including Ehlers-Danlos syndrome, scleroderma, skin cancer, or any other skin condition)?*

If Yes, Please list, Please mark N/A if no..*

Are you under a doctor’s care?*

If so, for what? Please mark N/A if no..*

Do you take ANY medications (prescriptions or non-prescriptions) including vitamins, over-the-counter medications and/or herbal supplements?*

If so, for what? Please mark N/A if no..*

Are there any topical products (both medical and non-medical) that you use on your skin on a regular or daily basis? *

If so, for what? Please mark N/A if no..*

Are you taking oral steroids (eg. prednisone, dexamethasone)? **

Do you have a pacemaker or external defibrillator? **

Do you have any metal implants under the area being treated? **

Do you have a history of light-induced seizures?*

Do you have a history of Herpes in the area being treated? **

Do you have any open sores or lesions? **

Have you had radiation therapy in the area being treated? **

Do you have a history of keloid scaring or hypertrophic scar formation? **

In the last 6 months, have you used any of the following? Anticoagulants or blood-thinning medications, photosensitizing medications or anti-inflammatories?*

List Product, Date Used: Please mark N/A if no. *

In the last 3 months, have you used any of the following products: glycolic acid or other alphahydroxy- or betahydroxyacid products, exfoliating or resurfacing products or treatments?*

If so, for what? Please mark N/A if no.*

Have you had any cosmetic procedures in the past 6 months?*

If so, for what? Please mark N/A if no.*

Have you had any permanent make-up, tattoos, implants, or fillers, including: but not limited to collagen, autologous fat, Restylane, ect.?*

If yes, please list locations and dates, Please mark N/A if no.*

In the last month, have you been treated with any Botulinums (eg. Botox or Dysport)?*

If yes, please list locations and dates, Please mark N/A if no.*

Have you taken Accutane (or products containing isotretinoin) or Tretinoin (eg. Retin-A, Renova) in the last 6 months?*

Have you had any unprotected sun exposure, used tanning creams (including sunless tanning lotions) or tanning beds/lamps in the last month?*

Are you pregnant or breastfeeding?*

Are your menstrual periods regular*

Do you have any condition or take any medication that affects the regularity of your periods (i.e. birth control, menopause, hysterectomy, polycystic ovarian syndrome, etc)*

Date of last menstrual period

Date

I understand that by providing information and submitting this form constitutes an agreement for treatment at Bene Beyond in the Aesthetics division. I also understand that I am entitled to maintain a provider-patient relationship with an outside primary care provider but should not overlap cosmetic procedures until released fully from all other providers of cosmetic services.

Signature*

Aesthetic Medical History Form

Please answer each of the following questions:

For Women Only