Surname *
First Name *
Date of Birth *
Sex * MaleFemaleOther
Address *
City *
Province * AlbertaBritish ColombiaManitobaNew BrunswickNova ScotiaNorthwest TerritoriesNewfoundlandNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon
Postal Code *
Email *
Ontario Health Card Number with Version Code (XXXX-XXX-XXX-XX)
Family Physician *
Occupation *
Do we have your permission to leave a message regarding your treatment or test results? * YesNo
Name
Phone Number
Do we have your permission to discuss your treatment, surgical care, or results with anyone else other than you? If yes, please list: * YesNo
Full Name
Relationship
How did you hear about our facility?
If friend/family member, please specify name.
What are your COSMETIC GOALS / AREAS OF INTEREST? *
Non-Surgical Treatments We specialize in a number of cosmetic medical and surgical procedures. Are you interested in discussing any of the following procedures? PLEASE CHECK ALL THAT APPLY BY HOLDING DOWN CTRL ON YOUR KEYBOARD Botox TreatmentBotox for headaches or hyperhidrosisWrinkle treatment with fillersLaser resurfacing for wrinkles and moreTreatment for blood vesselsTreatment for brown spotsSkin tightening treatmentsCellulite treatmentsLaser hair removalScar revision/stretchmark reductionSkincare consultation/acne treatmentsLeg vein treatmentsCoolSculptingHydraFacialLatisse (eyelashes)Other (please specify)
How soon would you like to have treatment/surgery? TodayVery SoonNear Future
Do you have any upcoming special events? YesNo
Have you ever had cosmetic procedures? (surgery/laser/medical) List below
Height *
Weight *
Please list all of your medications that you have taken regularly or occasionally in the past two weeks. Include any herbal or over-the-counter products:
Have you taken Aspirin, anti-inflammatory medications, blood thinners, St. John’s Wort in the past two weeks? YesNo
Have you taken any of the following in the past month: steroid, tetracycline, sulfa drugs, or antibiotics? YesNo
Have you taken accutane or gold therapy in the past six months? YesNo
Do you currently use Retin A, glycolics, AHA or other prescription skin medications? YesNo
Do you have any allergies? (medications, food, etc.) List Below.
Are you allergic to latex? YesNo
Are you allergic to adhesives? YesNo
Are you pregnant/breastfeeding? YesNo
Do you have abnormal periods? YesNo
Are you actively trying to get pregnant? YesNo
Are you prone to, do you have, or have you ever had any of the following conditions? PLEASE CHECK ALL THAT APPLY BY HOLDING DOWN CTRL ON YOUR KEYBOARD Autoimmune conditions ie: Lupus, Rheumatoid arthritis, etc.HIV/AIDS or any other immunosuppressive disorderAddiction to drugs or alcoholInfectionAnaphylaxis or similar reactionJoint replacementArtificial implantsKidney diseaseHormone imbalance/PCODPacemaker/DefibrillatorBleeding disorder/problemPhotosensitivity disorderCancer/Radiation treatmentPsychiatric/emotional disordersDiabetesSexually transmitted diseaseGlaucoma or other eye diseasesSeizure disorder/epilepsyFainting/DizzinessShinglesHigh blood pressureTransplantHeart problems/AnginaVaricose/Spider veinsHeadaches/MigrainesHepatitis/Liver diseaseAsthma/emphysema/TB/lung/breathing problemSleep apneaOther (please specify)
If you checked any of the above, please explain
Have you had any previous surgery? If yes, list below
Hobbies
Do you smoke cigarettes? YesNo
Do you smoke marijuana? YesNo
In order to establish your skin type, please tell us your ethnic heritage *
(Example: Asian, Northern European, Indigenous, Jamaican etc.)
Please check which best describes your reaction to sun exposure: Skin Type I: Never tans, always burns (extremely fair skin, blonde hair, blue/green eyes)Skin Type II: Occasionally tans, usually burns (fair skin, sandy/brown hair, green/blue eyes)Skin Type III: Often tans, sometimes burns (medium skin, brown hair, brown eyes)Skin Type IV: Always tans, never burns (olive skin, brown hair, brown eyes)Skin Type V: Never burns (dark brown skin, black hair, black eyes), Skin Type VI: Never burn (black skin, black hair, black eyes)
Any reactions to treatments? YesNo
Have you seen/are you seeing a doctor for your skin? YesNo
Have you been diagnosed with a skin condition (past/present)? If yes, list below.
List any topical, skin, or injectable medication?
Do you bruise easily? YesNo
Do you scar excessively (keloid scarring)? YesNo
Personal or family history of skin cancer? YesNo
Do you get cold sores (herpes)? YesNo
Difficulty with wound healing? YesNo
Skin infection/cellulitis? YesNo
Do you work outdoors? YesNo
Have you been in the sun/tanning bed or use self tanners in the past six weeks? YesNo
If you answered yes to any of the above, please describe:
How many sunburns have you had since childhood? NoneA fewMany
Products used:
Do you use sunscreen? YesNo
I certify that the preceding personal, medical, and skin history statements are true and correct. I am aware that it is my responsibility to inform the treatment provider of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
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