top of page
Home
About
Services
Initial Assessment Session
Botox
Dermal Fillers
PRP Therapy
Microneedling
Mesotherapy
Medical-Grade Chemical Peels
Laser Skin Treatments & Hair Removal
Blog
Contact
Log In
Intake
Form
We’re here to help you on your journey to looking and feeling your best. Please fill out the form before your Initial Assessment Session.
General Health Questionnaire
Client Information
First name
*
Last name
*
Email
*
Cell Phone
*
Alternative Phone
Address
*
Medical Information
Birthday
*
Year
Month
Month
Day
Age
*
Family Physician
*
Phone
*
Do you smoke? If so, how often?
*
Do you drink alcohol? If so, how often?
*
Have you ever been treated for:
*
Acne
Depression
Skin Disease
High Blood Pressure
Cold Sores
Diabetes
Cancer
Sinus
None
Other
List all medications you are currently taking (especially Accutane (Isotretinoin) or any photosensitizing drugs):
*
Are you pregnant?
*
Are You on Hormone Therapy / Birth Control?
*
Do you wear contact lenses?
*
List any medications you are allergic to: (incl. latex)
*
Do you have or have you had:
*
Heart problems
Herpes
Keloidal scarring
Cold sores
Pacemakers
Cancer/Melanoma
None
Other
Please explain:
*
Any photosensitive disorder? (lupus, porphyria, sun rash, etc.)
*
Past medical problems:
*
Personal Information
Have you had cosmetic surgery? If so, please list.
*
How do you want to improve your skin?
*
What previous skin care treatments have you had?
*
What skin care are you currently using?
*
Sun History and Lifestyle
Do you work inside or outside?
*
Do you use chemical sun tanning lotions?
*
Yes
No
If yes, when did you last use them?
*
When was your last sun exposure?
*
Do you use tanning beds?
*
Are your hobbies done mostly inside or outside?
*
When exposed to the sun without protection for about 1 hour, how does your skin react?
*
Burns always, never tans
Burns sometimes, sometimes tans
Burns always, something tans
Tans always
Ethnic Background:
*
Caucasian
Hispanic
Asian
Mediterranean
Middle Eastern
African
American
Please check all treatments/services that interest you:
*
Neurotoxin Injections ‐ Botox®
Dermal Fillers
PRP Therapy
Micro‐Needling
Mesotherapy
Medical-Grade Chemical Peels
Laser Skin Treatments & Hair Removal
How did you hear about our services?
*
Signature
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Submit
Log In
Home
About
Services
Initial Assessment Session
Botox
Dermal Fillers
PRP Therapy
Microneedling
Mesotherapy
Medical-Grade Chemical Peels
Laser Skin Treatments & Hair Removal
Blog
Contact
bottom of page
