Patient Information

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Today's Date: 

 

     

​​​​ Check if Minor (less than 18)
 

 

Address

Permission to contact PCP regarding care and to inform of treatment course:  Yes  No

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How did you hear of us?

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​​​​​   I hereby authorize medical treatment of the person named above, and agree to pay all fees and charges for treatments and services rendered. I understand that medical treatment may include a review of personal, social and medical history, discussion of the reason(s) for the visits), and may include photographs of the areas) being discussed and or treated before and/or after treatment. I have read and agreed to the above.
 
If the patient is a minor (under 18 years of age), the responsible parent or guardian must sign above, and fill in the information below.

Please note that we require a copy of your government-issued photo identification for your record.

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Personal Medical History

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Please mark all past and present mnedical conditions: Do you faint easily?  Yes  No  

 

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Personal Surgical History

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Procedure	Date

Have you ever had any surgical complications?  Yes  No
If Yes, Please describe

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Medications

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List al medications you are currently taking, both by mouth and topically, including prescriptions (such as birth control, blood thinners, etc.), over-the-counter treatments, vitamins, herbal supplements and creams. Please let us know the reason you are taking each medication.

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Medication	Dosage & Frequency	Length of Time Used	Reason Taking Medication

 

Are you currently, or have you recently, taken any medications containing Aspirin?  Yes  No
Have you been on Accutane therapy within the past 24 months?  Yes  No
Have you taken any steroid preparation(s) over the past year?  Yes  No

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Allergies

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 If you have no allergies at all, check this box and skip to the next section.

If you do have allergies, please check all items that you have had an allergic reation to: 

 Penicillin  Sulfa  Lidocaine  Novocaine  Eggs  Latex

If you marked any of the above, please describe the reaction(s):
Please list al other drug and food allergies, including products such as tape, and the nature of your reaction:

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Family Medical History

Please mark which of your relatives have or had the following conditions. List which blook relative are / were affected.

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	Mother	Father	Blood Relatives(s)
Allergies
Arthritis
Asthma
Caner(except skin cancer)
Diabetes
Eczema
Heart Disease
High Blood Pressure
Lung Disease
Psoriasis
Tuberculosis
Other skin condition
Basal Cell Carcinoma
Squamous Cell Carcinoma
Melanoma

Where you adopted?  Yes  No
If Yes, do you know your biological family's medical history?  No  Yes

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Social History

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Do you smoke?  Yes  No  I did, but I quit
Quitting date: 

Do you drink alcohol?  Yes  No

Recreational drugs?  No  Yes

If Yes, which and how often?
How often do you exercise?  Daily  1 x per week  2-3 x per week  4-6 x per week
Do you use sunscreen?  Daily  Always if sunny  Sometimes if sunny  Rarely / Never
What skin care products do you use?
Are you using birth control?  No  Yes
If Yes, method

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Review of Systems

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Have you had any significant weight change in the past year?  Yes  No
lb losslb gain
What is your height?
What is your current weight?

 

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COSMETIC & AESTHETIC INTEREST QUESTIONNAIRE

 

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Non Surgical Treatments for Face and Body

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Aesthetic Surgery

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Aesthetic Treatments

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