PATIENT INTAKE FORM
PATIENT NAME:
First Name
Last Name
DOB:
-
Month
-
Day
Year
Date
Gender:
Male
Female
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Are you currently pregnant, attempting to conceive, or breast feeding?
YES
NO
If the answer is yes, you are contraindicated to a chemical peel.
List all allergies:
Current Medications and Supplements:
Are you currently under the care of a physician?
YES
NO
If yes, why?
Please take a moment to carefully read the following list of conditions and questions below. Check any that have affected your health either recently or in the past. A referral from your primary care provider may be required prior to service being provided.
Wearing contact lenses
Hormonal Therapy
Diabetes
Migraines High level of stress
Cardiac or Circulatory Problems
HIV Positive
Blood Clots
Hepatitis
Recent Illness
Metal or Silicone Implants
Thyroid (over or under active)
High or Low Blood Pressure
Epilepsy or Seizures
Sinus Infection
Arthritis or Joint Swelling
Fibromyalgia
Lack of normal skin sensation
Multiple Sclerosis
Contagious Conditions
Recent Surgery
Difficulty relaxing
Heart Condition / Pacemaker
Tension Headaches
Skin Rashes
Diabetes
Dry Skin
Thrombosis/Phlebitis
Herpes Virus (cold sores)
Skin Cancer – or other
Are you allergic to any cosmetic ingredient, medication or food?
YES
NO
Please List:
List all health conditions currently undergoing treatment and within the past 12 months.
List all active treatments that you have had in the past 6 months.
(Laser, IPL, Dermaplaning, Microneedling, Microdermabrasion, Thermage, etc.)
Patient Skin Concerns and Goals:
Ethnicity- what is your genetic background?
(English, Irish, Latino, Middle Eastern, African American, etc.)
Lifestyle:
Smoking:
per day
Alcohol:
per day
Caffeinated Beverages:
per day
Water intake:
glasses (oz.) per day
Exercise:
Amount of sleep each night:
Current Daily Skincare Regimen:
AM
PM
Patient Signature:
Date:
-
Month
-
Day
Year
Date
Submit
Should be Empty: