Patient Registration

Patient Registration
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Occupation
Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?
Referred By:
Skin Care
Which of the following best describes your skin type?

Very Oily SkinLarge PoresAcneDry SkinSensitiveCombinationNormal
What is your daily skin care regimen?
How would you rate the overall quality of your skin?

PoorFairGoodVery Good
Are you currently using any topical medication (like Retin-A®) or exfoliating acids like salicylic or glycolic?

YesNo
If yes, explain:
Are you currently using or have you used Accutane® in the past 12 months?

YesNo
Do you wear contact lenses?

YesNo
Are you wearing them right now?

YesNo
What improvements would you like to see to your skin?
Sun History and Lifestyle
How often do you work outdoors?

FrequentlyOccasionallyRarely
How often do you use sunscreen?

FrequentlyOccasionallyRarely
How often do you tan or wear self-tanner?

FrequentlyOccasionallyRarely
Medical History and Allergies
Please list all current medications, prescriptions, and homeopathic supplements:
Please list all allergies:
Do you have or have you ever had any of the following?

CancerDiabetesHeart DiseaseHeart ProblemsHIV or Other Immune Deficiency DisordersEpilepsyLiver DiseaseHormone ImbalanceHerpes/Cold SoresHepatitisSkin Disorder
Previous Procedures
Which of the following have you had in the last three months?

BOTOX®Dysport®Xeomin®Fillers/JUVEDERM®Radiesse®Restylane®Voluma®MicrodermabrasionChemical PeelsLaser Hair RemovalPermanent MakeupSkin ResurfacingSkin RejuvinationSkin TighteningFacial Plastic/Reconstructive SurgeryOther
Are you pregnant or breastfeeding?

YesNo
Are you interested in learning more about any of the following?

MicrodermabrasionFillersChemical PeelsLaser IPLPRPSpecials/PackagesPlastic SurgeryOther
Checking this box is my signature to agree to receive text messages about my healthcare and for marketing purposes, including autodialed, from The Facial Center at the numbers below. I understand that this consent is not a condition of purchasing any goods or services, I can opt out at any time, message/data rates may apply per my phone plan, and opting-in includes acceptance of our Privacy Policy and Terms of Service.
(304) 205-6123
(304) 760-4000
Signature*
Type full name to sign
Date*

MonthDayYear
Date
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Patient Registration

Skin Care

Sun History and Lifestyle

Medical History and Allergies

Previous Procedures