Heartland Aesthetica New Patient Form
Patient Name
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Preferred Language
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
example@example.com
Employer
Occupation
Primary Doctor
Referring Doctor
How did you hear about us?
Website
Facebook
Instagram
Patient Referral
If you chose patient referral, who may we thank for your business?
Preferred Pharmacy
Have you been under the care of a physician or medical professional within the last year?
Yes
No
If yes, please explain:
Please list all surgeries including cosmetic surgeries:
Date of last Cosmetic Treatment
-
Month
-
Day
Year
Date
Do you have a history of cold sores?
Yes
No
If yes, please list your cold sore medications:
Have you taken any prescribed blood thinners, ibuprofen, or Aspirin in the last 48 hours?
Yes
No
If Yes, Please list:
Do you have a history of skin cancer?
Yes
No
If yes, please explain:
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Next
Do you have any piercings, tattoos, or permanent cosmetics?
Yes
No
If yes, where?
Do you use Retin-A, Renova, Adapalene, Hydroxyl Acid, Diferin, Glycolic Acid, AHA, Salicylic Acid, Vitamin A derivative products?
Yes
No
If yes, please list and describe last time used:
Do you use Acne Medications?
Yes
No
If yes, please list them:
Have you ever used Accutane?
Yes
No
If yes, when did you last use it?
Are you pregnant, or breastfeeding?
Yes
No
Do you form thick scars from cuts, burns or surgical procedures?
Yes
No
Do you have hyperpigmentation (darkening of skin) or hypopigmentation (lightening of skin) or marks after physical trauma?
Yes
No
Do you wear contact lenses?
Yes
No
Are you planning an event or vacation in the next 3-4 months that will expose you to the sun?
Yes
No
Do you have any metal implants (screws, plates) or a pacemaker?
Yes
No
Have you ever experienced claustrophobia?
Yes
No
Do you wear sunscreen?
Yes every day
No
Yes, but just during sun exposure
If yes, which brand and SPF?
Do you tan in a tanning salon?
Yes
No
If yes, when was the last time you went to a salon?
Smoking Status
Never smoker
Current every day smoker
Current social smoker
Cigar smoker
Former smoker
As a former smoker, when did you quit?
Alcohol Intake
Never Drinker
Less than 1 drink per day
2-3 drinks per day
3 or more drinks per day
Socially (weekends, events)
Allergies to medications and skin care products:
Back
Next
Past Medical History
Check any of the following medical conditions that you currently have or had have:
Medications
Type a question
Rows
Medication Name
Dose
Frequency
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Patient or Patient Representative Signature
*
Today's Date:
-
Month
-
Day
Year
Date
Submit
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