Patient Information
Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Gender
*
Please Select
Male
Female
Rather not to say
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian or Emergency Contact Details
Emergency Contact Name
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Data
Allergic to Medicine
*
Please Select
Yes
No
Not Sure
If Yes, Please List Them
Is Your Skin Prone to Keloids?
*
Yes
No
Not Sure
Have You Had Any Major Surgeries?
*
Yes
No
Not Sure
If Yes, Please List Them
Are You Planning a Pregnancy in the Near Future?
*
Yes
No
Not Sure
Do You Intend to Breastfeed?
*
Yes
No
Not Sure
Are You Taking Any Medications, Including Over-the-Counter Products?
Advil
High Blood Pressure
Antibiotics
Tylenol
Other
N/A
If Other, Please List Them
Latest Procedure History?
Botox
Filler
Collagen
Skinbooster
Thread
Laser
N/A
Referred By
Acknowledgment, Authorization and Waiver
I authorize Dermaster to perform the treatment or necessary procedure to me/ or to my (for Parent/Guardian) dependent.
*
I agree to terms & conditions provided by Dermaster. By providing my phone number, I agree to receive text messages from the business.
*
I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
*
All treatments are non-refundable but exchangeable for services of equal or lesser value within one year of purchase. You are financially responsible for all treatments received at Dermaster. I acknowledge that all information I provided int his form is true and accurate.
Patient/Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Please verify that you are human
*
REGISTER
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