arcticmedicalcenter.com - Aesthetics Medical Intake Form

Aesthetics Medical Intake Form
Name:

First NameLast Name
Date:

MonthDayYear
Date
Birth Date:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
E-Mail Address:
example@example.com
Emergency Contact (Name & Phone):
Primary Physician:
Do we have permission to contact you by phone or leave messages?

YesNo
Do we have your permission to show your photos for educational purposes?

YesNo
Are you pregnant and/or nursing?

YesNo
What size robe do you need?

S/MLXXL
Concerns
What concerns you most about the overall appearance of your skin? (Check all that apply)

AcneAcne ScarringAge SpotsBlackheadsBody AcneBroken Blood VesselsBumps on back of armsCelluliteCysts/NodulesDehydrated SkinDull ComplexionExcessive Facial HairFacial VeinsFine Lines/WrinklesFrequent BreakoutsLarge PoresLoss of Lashes/BrowsMelasma/PatchesBrown PatchesOily SkinRednessRough Skin TextureRosaceaSagging SkinSun DamageUnder Eye PuffinessDark CirclesOther:
How would you describe your skin?

OilyDryCombinationSensitive
How would you describe your stress level?

LittleModerateHighSevere
Do you feel your stress level may be affecting the health of your skin?

YesNo
Are you in good health overall?

YesNo
History
Are you currently under the care of a physician?

YesNo
Explain:
Do you have any allergies to foods or medications?

YesNo
Explain:
Are you currently on any medications either topical or oral?

YesNo
If yes, please list:
How do you heal after a breakout, cut, or scratch?

No ScarRedBrown (PIH)
Do you smoke?

YesNo
Are you prone to cold sores?

YesNo
If yes, date of last cold sore?

MonthDayYear
Date
Do you have an allergy to Latex?

YesNo
Do you tan in the sun or in tanning beds/booths?

YesNo
Please check the skincare products you are currently using:

CleanserTonerSerumMaskEye CreamMoisturizerSunscreenSelf TannerConcealerMakeupOther:
Anything else we should know?
By signing below, I acknowledge the answers I have provided are true and correct to the best of my knowledge.
Client Signature

Clear
Date

MonthDayYear
Date
Provider Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Aesthetics Medical Intake Form

Concerns

History