New Patient Intake Form

Name

First Last

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Date of Birth*

Primary Care Physician

Physician Phone Number

Emergency Contact

First Last Relationship to you

How did you hear about us?*

What is your main concern that brought you in today?*

MEDICAL HISTORY: (This information is necessary for your procedure)

Are you using any prescription medication?*

No
Yes

If yes, list:

Are you using any anti-coagulant (blood thinning) medication?*

No
Yes

If yes, list:

Are you using any herbal medications?*

No
Yes

If yes, list:

Do you have any ALLERGIES to any cosmetic ingredients?*

No
Yes

If yes, list:

Do you have any ALLERGIES to any medications or food?*

No
Yes

If yes, list:

Are you pregnant or trying to become pregnant?*

No
Yes

Do you use any hormone replacement therapy?*

No
Yes

Do you smoke?*

No
Yes

Do you use tanning beds?*

No
Yes

If yes, how often? Last tan?

Do you have any permanent makeup?*

No
Yes

Have you taken Accutane in the last 6 months?*

No
Yes

Are you currently undergoing chemotherapy or radiation?*

No
Yes

If yes, what for:

PLEASE SELECT ANY HEALTH PROBLEMS PRESENT OR PAST:*

If you selected Skin Cancer, what type?

PLEASE SELECT ANY CHRONIC SKIN DISORDERS:*

If you selected "Other", list:

PLEASE SELECT WHICH SKIN CONDITIONS CONCERN YOU MOST:*

If you selected "Other", list:

AS BEST YOU CAN, PLEASE LIST THE CURRENT PRODUCTS AND BRAND NAMES THAT YOU ARE CURRENTLY USING: (Cleanser/Exfoliant/Vitamin C/Moisturizer/Eye Cream/Sunscreen/Other)*

PLEASE SELECT ANY OF THE FOLLOWING WRINKLE, FILLER, OR FACIAL TREATMENTS YOU HAVE HAD:*

If so, by whom? When? What area?

Muscle Relaxants:

Kybella*

No
Yes

If so, by whom? When? What area?

Have you undergone cosmetic surgery?*

No
Yes

If YES, list area of the body:

Name of Physician who performed surgery:

Name

Date of surgery:

Consent*

I agree to the privacy policy.

Please sign:*

Electronic Signature

New Patient Form

MEDICAL HISTORY: (This information is necessary for your procedure)

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