Name
Email
Address
City
State
Zip
Telephone
Date of Birth
Your Age
What skin problems or concerns would you like to address? (check all that apply)
Hyperpigmentation (sun damage, age spots, freckles, etc.)
Melasma (brown patches, "mask of pregnancy")
Fine Lines and Wrinkles
Uneven skin tone and texture
Acne
Acne scars
Large pores
Overalll skin laxity (loss of elasticity)
Redness or Rosacea
Other:
Describe your skin type: (check all that apply)
Normal
Dry / Dehydrated
Oily
T-Zone / Combination
Sensitive
Resilient
Thick
Thin
Other:
Genetic Origin:
African American
Caucasian
Hispanic
Mediterranean
Middle Eastern
Asian
Native American
Other:
Your Current Skin Care Practices
What is your present skincare regimen as well as the products you are using?
Rate how committed you are to transform your skin?
1 (Not Committed)
2
3
4
5
6
7
8
9
10 (Totally Committed)
Are you Pregnant, trying to get pregnant, or lactating (nursing)?
Are you in the habit of going to tanning booths?
Last Visit?
Currently use or receive depilatories or waxing?
Last time?
Using any topical medications at this time?
What kinds of topical medications or what are their names?
Currently using any topical Retinoid prescriptions? (Retin-A/Renova/Differin/Tazorax/Avage)
If yes, what strength and for how long?
Have you used accutane in the past 6 months?
If yes, for how long and when did you stop?
Have you had a chemical peel within the last 14 days?
Have you had a facial treatment in the past?
Facial Surgery?
Laser Resurfacing?
Please describe your experience for any of the above:
Allergies
List any allergies with reactions
Mark any of the following illnesses you have or have ever had in the past:
Multiple Severe Allergies/Hypersensitivity to medications
Sensitivity/Allergy to Lidocaine
Autoimmune Disease
History of Cold Sores
Pace Maker
Lambert Eaton Syndrome
Parkinsons Disease
Neurological Disorders
Vision Problems
Hepatitis
Cancer
Myesthenia Gravis
Amyotrophic Lateral Sclerosis (ALS)
Multiple Sclerosis
Muscle Weakness
Acne
Depression
Skin Disease
High Blood Pressure
Diabetes
List any OTHER MEDICAL CONDITIONS not listed above that you currently have or have taken in the past
Previous hospitalizations and/or operations
Have you had plastic surgery or other surgery to your face/neck areas & when?
Are you taking any medications, vitamins, supplements at this time? (Antibiotics may increase sensitivity.)
If yes, please list them here:
Informed Consent Release
I
Patient Signature (Type your full name)
Date
