VI Peel® Patient Intake Form
Name
First Name
Last Name
Age
Sex
Male
Female
Date of Birth (DOB)
-
Month
-
Day
Year
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Date
/
Month
/
Day
Year
Date
Address
Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Select all skin concern(s) that you are seeking improvement upon.
Pigment
Yes
No
Aging
Yes
No
Acne
Yes
No
Rosacea
Yes
No
OTHER
Are you pregnant or breastfeeding?
Please Select
Yes
No
If yes, you are contraindicated for a chemical peel.
Do you have permanent makeup?
Please Select
Yes
No
Do you wear contacts?
Please Select
Yes
No
Do you currently have sunburn or wind burned skin?
Please Select
Yes
No
If yes, you are contraindicated for a chemical peel.
Have you recently had facial or body waxing or used at home depilatories?
Please Select
Yes
No
Do you have extended outdoor plans in the next 7 days?
Please Select
Yes
No
Do you plan to participate in vigorous exercise in the next 72 hours?
Please Select
Yes
No
Have you had any active skin care treatments in the past 21 days?
Please Select
Yes
No
If yes, how long ago?
List all topical products applied in the last 7 days
List all prescription medications currently taken and in the past two weeks.
Have you recently undergone any surgery or laser treatments in the area to be treated?
Please Select
Yes
No
If yes, please provide detail
Do you receive injectables? (Botox, Fillers)
Please Select
Yes
No
Do you develop Cold Sores?
Please Select
Do you have any known allergies or sensitivities? (Please list)
Describe your ethnic background (English, Hispanic, Italian, German, Asian, Native American, African American, etc
How would you describe your skin?
Please Select
Normal
Sensitive
Resilient
Please upload a current photo of your face/skin: (Front)
Browse Files
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Choose a file
No photos will be shared, and this form is HIPAA compliant. For consultation purposes only.
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of
Please upload a current photo of your face/skin: (Side)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a current photo of your face/skin: (Side)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
How did you find out about us?
Photo/Video Recording Consent for VI Peel Procedure
I understand that photographs and/or video recordings may be taken befor, during and after my VI Peel procedure for the purposes of documenting my treatment and monitoring results. I understand these images and recordings will become part of my confidential medical record.
I consent to photographs and/or video recordinga being taken for medical documentation purposes only.
Yes
No
In addition, I authorize the use of my photographs and/or video recordings for educational, marketing, advertising, social media, website, and promotional purposes. I understand that my identity will be protected to the extent possible and that I may revoke this authorization in writing at any time for future use.
I authorize the use of my photographs and/or video recordings for marketing and promotional purposes.
Yes
No
Groupon Pricing and Partnership Collaboration
Saw us on Groupon? Some people find us on groupon and are inclined to purchase from their site due to the promotional price listed. Golden Wellness guarantees the matching of the groupon price at our office and online to alleviate your worry or concern about purchasing through Groupon when you are checking out with us.
I would like to receive the Groupon market price for the VI Peel service with Golden Wellness
Yes
No
Submit
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