Medical History Form
Where insecurities meet x CONFIDENCE
Scar Aesthetics
Full Name
*
First Name
Last Name
What is your age?
*
What is your gender?
*
Please Select
Male
Female
N/A
Please choose the gender you classify as.
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
What service are you interested in?
*
Check the conditions that apply to you:
*
Pregnant/Breastfeeding
Cancer
Cardiac disease
Diabetes
Hypertension
Auto-immune
Epilepsy
Prone to Hyperpigmentation (dark spots)
Hiv/Aids/Compromised Immune System
Keloid Prone
Taking blood thinners
HSV (cold sores)
Other
Are you currently taking any medication?
*
Yes
No
Please list them. All information remains confidential. Entering false information can negatively affect your healing process. Enter n/a if none.
*
Do you have any known allergies or diseases? Answering yes is not always a denial.
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Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
*
Please Select
Yes
No
WHEN IN THE SUN- Do you typically burn, tan, or both?
*
Recent Botox injections? If so, when and where?
*
Do you use any recreational drugs as of now?
*
Please Select
Yes
No
Do you suffer from hyperpigmentation? Do you heal dark when you're cut?
*
Please Select
yes
no
What are your personal goals you are looking to achieve with this service?
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How old is this scar or stretch mark? (Enter N/A if this doesnt apply)
*
Possibly pregnant or breastfeeding?
*
Please Select
yes
no
Are you taking cortisone, retinol, or using any AHA/BHA'S?
*
Please Select
YES
NO
Recent surgeries and/or procedures? Currently being treated by a dermatologist?
*
How often do you consume alcohol?
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Daily
Weekly
Monthly
Occasionally
Never
Do you have any upcoming vacations where you'll be in direct sunlight?
Are you on any weight loss supplements or injections? (Semaglutide, tirzepatide, etc)
HAIR RESTORATION CLIENTS ONLY- PLEASE ANSWER ALL QUESTIONS ABOVE AND BELOW. SCAR CLIENTS MAY SKIP TO PHOTOS AND SIGNATURE PORTION.
Have you been seen by a dermatologist for this issue?
Yes
No
Type option 3
Type option 4
Do you have any autoimmune or blood disorders that led to hair thinning/lost?
Have you been diagnosed with any sort of alopecia? If so, which one?
Severe allergies?
Do you have any scalp disorders, open wounds, or sores? [Sebborheic dermatitis, psoriasis, Folliculitis, Wingworms, etc]
Scalp Surgery within the past year?
On blood thinners?
yes
no
Type option 3
Type option 4
Scalp treatments in the last 4 weeks? If so, what?
Any retinoids or exfoliating acids on scalp?
What led to the hair loss and how long have you suffered from this issue?
ALL CLENTS- PLEASE SUBMIT PHOTOS BELOW
Upload a clear photo of area you would like treated. PLEASE ENSURE LIGHTING IS CLEAR AND SCARS ARE EASILY VISIBLE.
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I agree that all information provided is true and correct.
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