• New Patient Form

  • Date
     - -
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • In which location is your consultation scheduled?*
  • How did you hear about us?*
  • Which areas of the FACE would you like to address?
  • Which areas of the BODY would you like to address?
  • Do you experience any of the following symptoms?
  • Are you happy with your current skincare?
  • Are you interested in financing options?
  • Have you had any of the following procedures?*
  • Please check a box if it applies to you:
  • Do you suffer from any of the following

  • Skin Type Worksheet

  • What is the color of your eyes?*
  • What is the natural color of your hair?*
  • What is the color of your skin? (unexposed areas)*
  • Do you have freckles on sun-exposed areas?*
  • What happens when you stay in the sun too long?*
  • To what degree do you turn brown?*
  • Do you turn brown several hours after sun exposure?*
  • How does your face respond to the sun?*
  • When did you last expose yourself to the sun, tanning bed or self-tanning creams?*
  • Do you expose the area to be treated to the sun?*

  • Worksheet Results

  • Fitzpatrick Skin Type: I (0-7)

  • Fitzpatrick Skin Type: II (8-16)

     

  • Fitzpatrick Skin Type: III (17-25)

  • Fitzpatrick Skin Type: IV (25-30)

  • Fitzpatrick Skin Type: V-VI (Over 30)

  • Lastly, would you like to receive marketing SMS and/or emails from Dermacare Medical Aesthetics?*
  • Should be Empty: