fcldspa.com - Spa Skin Care History

THE FLORIDA CENTER FOR LASER DENTISTRY MEDICAL SKINCARE HISTORY
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Do we have Permission to Text you:
DOB:

MonthDayYear
Date
Emergency Contact:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Please Check if you have any of the Following Health Conditions:
PLEASE LIST ANY OTHER HEALTH CONDITIONS NOT LISTED ABOVE:
PLEASE LIST ANY MEDICATIONS YOU ARE TAKING OR SUPPLEMENTS:
PLEASE LIST ANYTHING YOU ARE ALLERGIC TO:
ARE YOU CURRENTLY PREGNANT:
ARE YOU CURRENTLY TRYING TO GET PREGNANT:
HAVE YOU EVER USED ACCUTANE:
IF YES, WHEN DID YOU LAST USE IT:
DO YOU USE RETIN-A OR TENTINOIN PRODUCTS:
HOW OFTEN PER WEEK:
DO YOU USE ANY OTHER TOPICAL PRESCRIPTION CREAM FOR YOUR SKIN:
IF YES, PLEASE LIST THE NAME OF THE TOPICAL PRESCRIPTION:
DO YOU CURRENTLY TAKE BIRTH CONTROL OR ANY HOMONE MEDICATIONS:
DO YOU SUFFER FROM COLD SORES:
DO YOU SMOKE:
HOW OFTEN:
DO YOU FORM THICK OR RAISED SCARS FROM BURNS OR CUTS:
DO YOU HAVE HYPERPIGMENTATION (DARKENING OF SKIN) OR HYPOPIGMENTATION (LIGHTENING OF SKIN) OR MARKS AFTER PHYSICAL TRAUMA?
PLEASE DESCRIBE:
PLEASE CHECK WHICH SKIN TYPE BEST DESCRIBES YOU:
DO YOU REGULARLY USE TANNING SALONS OR SUN BATHE?
DO YOU USE SUNSCREEN DAILY:
ARE YOU INTERESTED IN MEDICAL GRADE SKIN CARE PRODUCTS:
PLEASE DESCRIBE WHEN YOU LOOK IN A MIRROR WHAT YOU WOULD LIKE TO CHANGE ABOUT YOUR SKIN:
I CERTIFY THAT THE PRECEDING MEDICAL, PERSONAL AND SKIN HISTORY STATEMENTS ARE TRUE AND CORRECT. I AM AWARE THAT IT IS MY RESPONSIBILTY TO INFORM THE ESTHETICIAN OR DOCTOR OF MY CURRENT MEDICAL OR HEALTH CONDITIONS AND UPDATE THIS HISTORY. A CURRENT HISTORY IS ESSENTIAL FOR THE CAREGIVER TO EXECUTE APPROPRIATE TREATMENT PROCEDURES:
SIGNATURE:
DATE:

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Date
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THE FLORIDA CENTER FOR LASER DENTISTRY MEDICAL SKINCARE HISTORY