• CLINIC RECORD

    CLINIC RECORD

  • Date of Birth:*
     - -
  • Date Today:*
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  • What are your actual problem:*
  • Is this your first visit?*

  • For Women’s

  • Are you pregnant?*
  • Are you taking birth control pills?*
  • Image field 84
  • Are you presently under a physician’s care for any current condition or other problem?*
  • Are you presently using (or used in the past) Botox, Fillers, PDO threads or another injectable products?*
  • Are you now using, or have you ever used any medicine cream or moisture?*
  • Do you have any important antecedents of Cancer or important diseases in your Family?*
  • Are you presently taking any medications?*
  • Have you had or has cancer?*
  • Do you often experience stress?*
  • Do you smoke?*
  • Allergies?*
  • Did you used Laser procedures, Ultrasound, Hifu or another technology machines?*
  • Please check if you have any medical conditions or if you are affected by or have any of the following:*
  • Date Signed*
     - -

  • Consent to Treatment of Minor

  • By signature below, I hereby authorize to Caras Facial Center members, Doctors, Esthetician or Health providers to Administer treatment or procedure on bodywork or facial to my child or dependent as they deem necessary.

  • Date Signed*
     - -
  • Should be Empty: