lauranp.com - New Patient Information Aesthetics

New Patient Information Aesthetics
Date:

MonthDayYear
Date
Client Name:
DOB:

MonthDayYear
Date
Age:
Gender:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Email Address:
example@example.com
Employer:
Occupation:
Work Phone:
Please enter a valid phone number.
Is it okay to contact you via:

mailemailhomeworkcell
Emergency Contact:
Relationship:
Phone Number:
Please enter a valid phone number.
How did you hear about us?
**This office charges a $30.00 cancellation fee if a 24 notice is not given.***

What concerns would you like to have addressed?
Age Spots/Sun Spots
Acne
Redness on face, neck, &/or chest
Acne Scars
Veins (where):
Tattoo removal (where):
Wrinkles &/or lines (where):
Unwanted Hair (where):
Skin Care Products
(We recommend medical skin care products to enhance and maintain your in office procedures).

MEDICAL HISTORY
Do you have any health/medical conditions?
Do you take blood thinners (Heparin, Coumadin, Warfarin, Vitamin E)?
Do you currently use retinols (Retin-A, Renova) or Differin?
Are you currently using or have you ever used Accutane
When:
Are you currently using oral or topical antibiotics?
Type:
Are you currently using hormonal birth control or hormone replacement therapy?
Type:
Do you take any other prescription OR over-the-counter medications?
Are you allergic to any medications?
Are you sensitive/allergic to any of the following?

Alpha-hydroxy acidHydroquinonePreservativesFragrancesLatex
Are you pregnant or breastfeeding?
Are you currently considering/planning a pregnancy?
Do you have a history of cold-sores, fever blisters, or herpes?
Are you currently on any mood altering or anti-depression medication? (If yes please list)
Do you have a personal or family history of seizures or seizure disorders?

Are you currently having or have you ever had:

	When:	Were you happy with the results?
Microdermabrasion
Electrolysis
Waxing
Laser hair removal
Laser vein removal
Sclerotherapy
Cosmetic peels
Collagen injections
Restylane
Radiuses
Botox

Any other injectables or implants in areas you are considering having treatments?
Permanent (tattooed) make-up?

YesNo
If so, where:
Facial surgeries?

YesNo
If so, where:
Please list all allergies

New Patient Information Aesthetics