Medical Skin History

The Power of Prescription Skin Care

Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
Our Proccess

Completing this form allows our expert pharmacists to:
1. Evaluate your needs.
2. Create your individualized medical-grade skincare regimen.
3. Send the prescription to your provider for an approval.
We won’t contact you for payment until your prescription has been approved by a provider.
Full Name*

First Last
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
We will never SPAM or sell email addresses to third parties.
Phone:*
ex. 555-555-5555
Gender*

FemaleMaleOther
Birthdate: (You must be over 18)*
ex. 01/05/1960
What is the best way to contact you?*

Phone callEmailTextAll
Are you allergic to anything?*

NOYES
If yes, please list allergies:
Have you had skin cancer?*

NOYES
If yes, please list area(s):
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Have you had any of these health conditions in the past or present? *

Skin cancerHormone imbalanceThyroid conditionHysterectomyDermatitisEczemaPsoriasisFever blistersDry skinRosaceaImmune disordersHyperpigmentation of skinSkin diseaseMelasmaAcneScarringNONEOther
Do you smoke or chew tobacco products everyday?*

NOYES
List any oral MEDICATIONS you take daily:
List all oral VITAMINS or HERBS you take daily:
List all skin products you use routinely.
Are you sensitive or allergic to any of the following?*

TretinoinAdapaleneKojic acidHydroquinoneHormonesDMAERetinolPeptidesScrubs / PeelsTazaroteneGlycolic acidAlpha hydroxy acidFragranceNONEOther
Female Clients
Are you pregnant or trying to become pregnant?

NOYES
Are you...?

PremenopausalPerimenopausalPostmenopausal
Skin Care History
Skin type? Select all that apply.*

DryNormalOilyCombinationSensitiveOther
Do regularly wear sunscreen?*

YesNo
What conditions would you like to improve?*

AcneOily SkinDry SkinBumpsLarge PoresMelasmaRednessBrown SpotsSun DamageMiliaSagging SkinRosaceaLines & WrinklesHealthy AgingWhite spotsScarringAge ManagementKeratosis PilarisHyperpigmentationHypopigmentation
List any additional conditions you would like treated:
Do you already have a prescriber that ProCompounding Pharmacy can send a recommendation to?*

YesNo
Provider's name:
Provider's phone number:
Photos that will be beneficial in evaluating your skin care needs.

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I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release ProCompounding Pharmacy and/or the skin care professional from liability and assume full responsibility thereof.*

I understand.
OPTIONAL: I grant permission to ProCompounding Pharmacy to use photos of my progress for marketing purposes business listing pages such as Instagram.

I grant permission.
Date*

MonthDayYear
Signature*
Please upload current picture identification (drivers license, state identification, passport, etc...)*

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The Power of Prescription Skin Care