Consultation FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastToday's Date Date of Birth *AgeSexMaleFemaleHome AddressEmail *Employer AddressPhoneOccupation Preferred method for confirming appointmentsHome Phone Work Phone Cell Phone EmailReferred byPhysicianInternet SearchFacebookInstagramMagazineTelevisionNewspaperIf you were reffered by an individual please state their name in full so that we may thank them:IF PATIENT IS UNDER 18 , PLEASE PROVIDE GUARDIAN INFORMATION Name *FirstMiddleLastRelationship to patientParent GuardianSibling Other Other Date of BirthAgeSexMaleFemaleContact info same as aboveYesNoHome AddressEmail *PhoneEmployerOccupation EMERGENCY CONTACT INFORMATIONSame as GuardianYesNoRelationship to patientParent Sibling OtherOtherName *FirstMiddleLastEmail *Phone NumberSKIN HISTORY AND HEALTH ASSESSMENT Patient NameAgeSexMaleFemaleCOSMETIC PROCEDURES DONE IN THE PASTMicrodermabresionYesNoChemical Peel(s)YesNoLaser ResurfacingYesNoPhotofacial/IPLYesNoMicroneedling+PRPYesNoFacial SurgeryYesNoToxins: i.e. Botox/DysportYesNoFillers: i.e. Juvederm/RestylaneYesNoKybellaYesNoIf "YES" to any , please provide procedure+dateSKINAcne or BreakoutsYesNoOily SkinYesNoSensitive SkinYesNoPigmentationYesNoRosaces/RednessYesNoFlakiness/Dryness/TightnessYesNoMelasmeYesNoEczema/PsoriasisYesNoCold SoresYesNoIf "Yes" to any of the above, please elaborate:Ethnicity:CaucasionAfricanLatin/HispanicAsianMiddle EasternindianOtherAre you currently pregnent or breastfeeding?YesNoAre you currently going through menopause?YesNoDo you wear sun protection daily?YesNoDo you have a history of using bleaching/brightening creams?YesNoIf "YES", last date of useDo you have a history of using retinoic acid?YesNoIf "YES", last date of use:Has your skin been aggressively exfoliated in the last 2 weeks?YesNoHave you ever had any burning/irritation with sunscreens?YesNoHave you ever used tanning beds?YesNoWhat skin care products do you currently use?CleanserExfoliatorRetinolMoisturizerSerumFacialOtherCURRENT MEDICAL CONDITIONSHeart DiseaseYesNoLung ConditionYesNoStomach ConditionYesNoLiver DiseaseYesNoKidney DiseaseYesNoAuto-Immune DiseaseYesNoCancerYesNoDiabetesYesNoChronic Medical ConditionYesNoBleeding/Clotting ProblemsYesNoHepatitisYesNoHIVYesNoBlood Bourne IllnessesYesNoIf "YES" to any of the above , please elaborate:ADDITIONAL MEDCAL CONDITIONS Check the Box if you have diagnosed or ever received Treatment for any of the followingAlcohol abuse/ AlcoholismNervous BreakdownDrug abuse/ Addiction Phycological/ Emotional problems Depression Personality disorderBipolarSchizophreniaClaustrophobia/ Panic attacksBody Dismorphic Disorder (BDD)Eating Disorder/ anorexiaCurrently in therapy/ counselling Currently confused , depressed/ having sucidal thoughts?Is there violence in your home Is anyone threatening you Is there someone close to you, or are there members of your family who strongly object to you having cosmetic treatment?Do you smoke?YesNoIf "YES" how frequently?Do you consume alcohol?YesNoIf "YES" how frequently? Do you have any allergies to any of the following?Medication/Drugs Creams / lotion FoodMake upIf "YES" please explainDo you have a Family history of the following?AsthmaHeart diseasesDiabetesSkin Cancer If "YES" please explain Please list all the medications that you are currently taking ( including any form of birth control or vitamins/ supplementsPlease provide the name and approximate data of any surgery (cosmetic or medical necessity) that you have hadWhat is your primary skin concern?Please list anything else you would like the physician to know What treatment are you interested in Please TickMedical Grade Skin CareChemical PeelsLaser Hair RemovalScar Minimization Anti-Wrinkle injectionPigmentation LaserCrystal MicrodermabrasionSkin Tightening Dermal FillersNon Invasive Fat Reduction Prescription Facials Radio Frequency +Micro needling Cellulite Reduction Stretch Marks Removal Redness / Red Vein removalSubmit
