Final Medical History Form

Medical History Form
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Medical History: Do you have any of the following? Please check all that apply.
Acne
Myasthenia Gravis
Numbness
Hepatitis
Psoriasis
Blood Clot (s)
Diabetes Mellitus
Easy Bruising
Depression
Current Use of Antibiotics
Heart Disease
Herpes/Cold Sores
Autoimmune Disease
Amyoptrophic Lateral Sclerosis
Eczema
Blood Disorder
Eaton Lambert
Anxiety
Cancer
Recent Illness
Nicotine Use
Are you currently taking any medication?*
Please list medications
Have you ever had an allergic reaction to any of the following? Check all that apply.*
Cosmetics
Sunscreen
Fragrance
Iodine
Shellfish
Food
Latex
Do You Have Allergies to Medications and to Foods such as Eggs, Egg Products and Albumin:
List all Allergies to Medications and to Foods such as Eggs, Egg Products and Albumin:
Are you currently taking any of the following? Check all that apply.*
Asprin
Accutane
Warfarin/Coumadin
Advil/Naprosyn/Motrin/Ibuprophen
Lovenox/Plavix
Have you taken any supplements and topical serums, oils, or creams in the last 2 weeks. If yes please select the ones that apply
Vitamin E
Vitamin A
Tretinoin/Retin A
Omega 3 Fatty Acids/Cod Liver Oil/CoQ10
Gingko Biloba/Garlic/Ginger
Have you had any of treatments listed below? Please check all that apply.
Chemical Peel
Microneedling
Botox/Dysport/Xeomin
Fillers/Sculptra
Laser
Platelet Rich Plasma/Fibrin
HydraFacial
IPL/BBL/Moxi
I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission. I agree to pre and post procedural photographs and that they will be a part of my medical record. I also authorize the use of these pictures to be used for professional medical or promotional purposes as deemed appropriate by Enrichment Skin Solutions including but not limited to display of these images on electronic digital networks, scientific medical publications, lay publications, or during lectures to medical or lay groups for the purposes of informing the medical community or general public about aesthetic or medical treatment procedures available at Enrichment Skin Solutions. I agree that all information and images collected by Enrichment Skin Solutions is the sole property of Enrichment Skin Solutions.
I understand, have read and completed this intake form truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindication and/or irritation to the skin from treatments received. The treatment received is voluntary and I release this institution and/ or skin care professional from liability and assume full responsibility thereof. By signing this form, you agree that you have read this form carefully and considered the side effects, risks and uncertainty of the outcome and decided the treatment is still in your best interests. You have discussed all the details of the treatment plan, past treatments and your medical history with your clinician and shared all the information your clinician may need to plan a treatment. You agree that the balance of the benefits and risks to you overall favor the use agreed upon treatment(s). You understand that the initial treatment of side effects and complications is included in the cost of the procedure and therefore no refunds are issued due to any of the above occurring. You understand that photographs are taken and stored as per any/all governing body guidelines which may be up to 10 years.
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MonthDayYear
Date
Email
example@example.com
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Medical History Form

Medical History: Do you have any of the following? Please check all that apply.

Have you ever had an allergic reaction to any of the following? Check all that apply.*

Are you currently taking any of the following? Check all that apply.*

Have you taken any supplements and topical serums, oils, or creams in the last 2 weeks. If yes please select the ones that apply

Have you had any of treatments listed below? Please check all that apply.