Patient Information


Today's Date: 

 

Title: Dr. Mr. Mrs. Ms.  
 Name (Last, First, Middle)

Gender

 Age

 Birthdate

 

 Street Address

 City, State & ZIP

 

 

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Permission to contact PCP regarding care and to inform of treatment course: 

How did you hear of us?


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Would you like to receive email announcements on special discounts, new products, or procedures?.... 

Authorization


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.
 

Reset Signature


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.

 

 Date


Personal Medical History


Please mark all past and present mnedical conditions:

 Cardiovascular:







Pulmonary:







​​​Neuromuscular:








Psychological:







 Ears / Nose / Throat:










Eyes:







Endocrine:




Hepatic: 




Renal:



Hematology:





  Gastrointestinal:






Allergic / Immunologic / Infectious:







Dermatological:










Cancer:








Do you faint easily? 
 
 Date
 

For Females Only:  
Do you have any personal history of breast cancer? 

 
 

Are you still in treatment? 
Do you have any family history of breast cancer? 
Was it normal? 
Are your currently pregnant? 
If No, are you planning to? 
Are you currently nursing? 
Have you ever had a Cesarean (C-Section)? 
For breast-related surgical patients only:

 


Personal Surgical History


  Procedure   Date
 
 
 
 
 


Have you ever had any surgical complications? 


Medications


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
 



 



 
 



 
 


 


 

 
 Date


Are you currently, or have you recently, taken any medications containing Aspirin? 
Have you been on Accutane therapy within the past 24 months? 
Have you taken any steroid preparation(s) over the past year? 


Allergies




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



Family Medical History

Please mark which of your relatives have or had the following conditions. List which blook relative are / were affected.
    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? 
If Yes, do you know your biological family's medical history? 

Social History


Do you smoke? 

Quitting date: 


Do you drink alcohol? 

Recreational drugs? 


How often do you exercise? 
Do you use sunscreen? 

Are you using birth control? 


Review of Systems


Have you had any significant weight change in the past year? 


 
 

 


COSMETIC & AESTHETIC INTEREST QUESTIONNAIRE

 
 
Date

 


Non Surgical Treatments for Face and Body


 




 






 


Aesthetic Surgery


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Aesthetic Treatments