Patient Information
Today's Date:
Permission to contact PCP regarding care and to inform of treatment course:
How did you hear of us?
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.
Please mark all past and present mnedical conditions:
Do you faint easily?
Personal Surgical History
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.
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.
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
Non Surgical Treatments for Face and Body
Aesthetic Surgery
Aesthetic Treatments