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Face
Microneedling
Microneedling Eclipse PRP
Micro-Needling / Skin Pen
BB Glow Microneedling
Fibroblast Skin Tightening
Laser Skin Tightening
IPL Photo Rejuvenation
Dermaplaning
HydraFacial
Microdermabrasion
RF Cautery
Ultrasonic Scrubber
Oxygen Therapy
L.E.D. Light Therapy
Beauty Enhancements
Botox and Fillers
Eyelash and Brow Tinting
Eyelash Enhancement
Hyaluron Pen
Permanent Make Up
Chemical Peels
Jessner / TCA Facial Peels
Obagi Blue Peel Radiance
Rejuva Peel
Hair
Laser Hair Removal
Electrolysis
Hair Restoration
Body
Skin Rejuvenation
IPL Photo Rejuvenation
Laser Skin Tightening
Micro-Needling / Skin Pen
Microneedling Eclipse PRP
RF Cautery
Fibroblast Skin Tightening
Body Contouring
Skin Care
Obagi
Skin For Life
SkinCeuticals
ZO® Skin Health
Blog
Contact Us
Online Consultation
Patient Medical History
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Patient Medical History
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Patient Medical History
* Required field
Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Cell Phone
Email Address
Occupation
Employer
Are you currently under the care of a physician?
*
Yes
No
If yes, please explain:
Are you currently under the care of a dermatologist?
*
Yes
No
If yes, please explain:
What topical medications or creams are you currently using?
How did you hear about us or who referred you?
Tick Yes or No
Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation?
*
Yes
No
Recent Surgery or injury?
*
Yes
No
If yes, please specify what kind of surgery or injury:
Are you currently on any mood altering or depression medications?
*
Yes
No
Have you ever used Accutane?
*
Yes
No
If yes, when did you last use it?
Do you have a pacemaker?
*
Yes
No
Any previous history of laser hair removal?
*
Yes
No
If so, date last treated?
Date Format: MM slash DD slash YYYY
Area(s)
Do you have heart/lung disease?
*
Yes
No
Are you Pregnant?
*
Yes
No
If so, due date?
Date Format: MM slash DD slash YYYY
Are you breastfeeding?
*
Yes
No
Do you have HIV?
*
Yes
No
Do you have keloid formation or scares that haven’t healed smoothly?
*
Yes
No
Do you have any skin disorders e.g. psoriasis, vitiligo, cancer, etc?
*
Yes
No
Do you have cold sores?
*
Yes
No
If yes, when was the last?
Are you diabetic or have endocrine disorders?
*
Yes
No
Do you have hepatitis?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Do you have any clotting problems?
*
Yes
No
Do you have a tattoo(s) in the area(s) that you want treated?
*
Yes
No
Have you sunbathed or been in a tanning bed within the last 2 weeks?
*
Yes
No
Does your skin remain discolored after healing from a cut?
*
Yes
No
Have you taken antibiotics in the past 2 weeks?
*
Yes
No
Which of the following best describes your skin? Choose only one.
*
Always burn, never tan
Always burn, sometimes tan
Sometimes burn, tan somewhat
Rarely burn, tan with ease
Moderately pigmented, never burn
Describe your skin. Select all that apply
*
Oily
Dry
Combination
Normal
Sensitive
Texture issues
Freckled
Mature
Wrinkled
Melasma
Aged spots
Rosacea
Eczema
Psoriasis
Acne
Scarred
Large pores
Sun-damaged
Broken surface capillaries
White/blackheads
Hypo/Hyper pigmented
What services are you interested in or would like more information on? Select all that apply
*
Weight loss
Fat reduction
Body contouring
Skin tightening
Hair removal
Botox
Chemical peel
Acne treatment
Age spots removal
Sun damage
Wrinkle reduction
Resurfacing
Co2 or Laser 360
Tattoo removal
Leg vein removal
Botox
Filler injections
Hormone replacement
Other
I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician of my current medical/health conditions and to update this history as needed. I understand that a current medical history is essential for the technician to execute appropriate treatment procedures.
Date
Date Format: MM slash DD slash YYYY
Policies
Appointments: All visits are scheduled by appointment. It is our policy to book ample time for your visit and we do our best to minimize patient waiting time. If you should need to cancel or reschedule an appointment, we require at least 24 hours advance notice. Payments: All payments are due at time of service. All payments are non-refundable. If paying upfront for multiple sessions, those payments are non-refundable. We do not carry balances for treatments rendered. I understand and acknowledge that payments for the above procedure are non-refundable and due on the day services are rendered. By my signature below, I certify that I have read and fully understand the contents of the policies listed.
Date
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.
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Face
Micro-Needling / Skin Pen
Microneedling Eclipse PRP
BB Glow Microneedling
Fibroblast Skin Tightening
Laser Skin Tightening
IPL Photo Rejuvenation
Dermaplaning
HydraFacial
Microdermabrasion
RF Cautery
Ultrasonic Scrubber
Oxygen Therapy
L.E.D. Light Therapy
Menu
Micro-Needling / Skin Pen
Microneedling Eclipse PRP
BB Glow Microneedling
Fibroblast Skin Tightening
Laser Skin Tightening
IPL Photo Rejuvenation
Dermaplaning
HydraFacial
Microdermabrasion
RF Cautery
Ultrasonic Scrubber
Oxygen Therapy
L.E.D. Light Therapy
Beauty Enhancements
Botox and Fillers
Eyelash and Brow Tinting
Eyelash Enhancement
Hyaluron Pen
Permanent Make Up
Menu
Botox and Fillers
Eyelash and Brow Tinting
Eyelash Enhancement
Hyaluron Pen
Permanent Make Up
Chemical Peels
Jessner / TCA Facial Peels
Obagi Blue Peel Radiance
Rejuva Peel
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Jessner / TCA Facial Peels
Obagi Blue Peel Radiance
Rejuva Peel
Hair
Laser Hair Removal
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Hair Restoration
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Hair Restoration
Body
Skin Rejuvenation
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