• CONTACT US

    Patient Intake

CLIENT CONTACT INFORMATION


PHONE NUMBERS


EMERGENCY CONTACT



CLIENT MEDICAL INFORMATION

AREAS OF INTEREST

PREVIOUS COSMETIC PROCEDURES

GENERAL HEALTH QUESTIONS


MEDICATIONS


ALLERGIES


FOR OUR FEMALE PATIENTS


MEDICAL HISTORY


SURGICAL HISTORY

SOCIAL HISTORY


SKIN-RELATED HEALTH QUESTIONS

HERITAGE

(Example: Asian, Northern European, Indigenous, Jamaican etc.)


FITZPATRICK SCREENING SKIN TYPE


SKIN HISTORY


CURRENT SKIN CARE


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.