Client Consultation Questionnaire

THE DE PIERI CLINIC

HEALTH AND AESTHETICS
I. Registration Form

Welcome to The De Pieri Clinic
First Name (as it appears on your care card):*
Surname (as it appears on your care card):*
Middle Name(s):
Preferred Name:
Birth Date:*

MonthDayYear
Date
Provincial Personal Health Number*
or other provincial health number
Sex*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (cell preferred)*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email*
example@example.com
How do you prefer to be reminded of your appointments?*

Text MessageEmail
Please upload a photo of yourself as an identifier*

Browse Files

Cancelof
Family Physician INCLUDING FIRST NAME OR INITIAL*
Type "no GP" if necessary
What is your occupation
Emergency Contact*
Type "none" if necessary
Emergency Contact Phone Number*

Area CodePhone Number
Preferred Pharmacy
How did you hear about us?

FacebookInstagramWebsiteWord of MouthOther
II. Treatment Consultation Questionnaire
Primary concern:*
Please check off any of the following concerns that you may have:
Skin:

Pigment/Uneven ToneDehydrated SkinAcne scarringSun damageRosacea/rednessBlackheads/whiteheadsWrinkles/fine linesBroken capillariesExcessive oil/shineFacial volume lossBreakouts/acneRash
Eyes:

WrinklesDark circlesPuffiness
Lips:

Volume LossDehydration
Check any of the following that might interest you:

Botox/XeominDermal Fillers/Facial ContouringSun damage correctionSkin ResurfacingDouble chin reductionLaser Hair RemovalChemical PeelTreatment for Cellulite/Stretch MarksMole & Skin Tag RemovalBody SculptingTreatment for Hair LossNaturopathic CareNutrient InfusionsBio-identical Hormone TherapyTreatment for excessive sweatingChronic Migraine TreatmentMedical grade skin care products
Are you required to work outdoors?*

YesNo
List any allergies:*
or type "none"
Please list any medications and/or supplements that you currently take:
Have you had any cosmetic procedures done previously?

MicrodermabrasionChemical PeelBotox/XeominDermal FillerIPL photo rejuvenationLaser Hair RemovalLaser Skin ResurfacingOther
Plastic Surgery or other surgeries relevant to the treatment area
Specify the dates of each
Ethnicity can affect how your skin responds to treatments (particularly laser treatments). How would you best describe your ethnic heritage?

Caucasian - Celtic or EuropeanCaucasian - MediterraneanMiddle Eastern, Asian, HispanicSouth Asian/Indian or IndigenousAfrican
How would you describe your skin's reaction to the sun?

Always burn, never tanSometimes burn, but always tanAlways burn, but sometimes tanNever burn, always tan
What skincare line/products do you use?
Do you use retinol or vitamin A-derived products?*

YesNo
If yes, when did you last use them?
Have you used acne medication?*

YesNo
If yes, when did you last use it?
Do you get cold sores?*

YesNo
How often?
Do you smoke?*

YesNo
If yes, how long have you smoked? How many per day?
How many units of alcohol do you typically drink per week? (1 unit = 1 glass of wine, 1 beer, or 1oz of spirits)*

none1-56-1011-15over 15
We look forward to welcoming you to our clinic! Please understand that any appointment cancellations require at least 24 hours notice. Same day cancellations or no-shows may be subject to a $60 fee. Patients who no-show twice may not be permitted to schedule future appointments.*

I accept
6-1353 Ellis Street, Kelowna, BC V1Y 1Z9 | (250) 448-7408 | www.thedepiericlinic.com
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THE DE PIERI CLINIC

I. Registration Form

II. Treatment Consultation Questionnaire