Patient Information Form

HIPPA PRIVACY NOTICE:

We take your privacy very seriously.
We will not release any information to an outside source unless we have obtained your written content. If you need any information releases, your clinician will provide you with the appropriate forms. 

TO SAVE TIME ON YOUR FIRST VISIT...You can complete the following New Patient Form and submit it securely through our website. If you prefer to print the form and bring it along with you, please Click Here

General Information (Required):

How did you hear about us?

What is the main reason for your consultation/visit with us? (Check all that apply)

Skin History:

Have you ever been treated for any of the above conditions before?
Are you currently taking medication for any skin condition?
Are you currently taking or have you ever taken any of the following:
Do you get cold sores or fever blisters? 
Do you form thick or raised scars (Keloid)?
Do you develop hyperpigmentation or dark spots?
When were you last exposed to sun or tanning booth?
Do you use self-tanning products?
Have you used any of the following hair removal methods in the past 6 weeks?

Cosmetic History:

Have you ever had any of the following?
What type/brand of skin care products do you currently use?
Please list all cosmetic injectables such as: Botox, Juvederm, Radiesse, collagen, fat, lifting threads or other products you’ve had:

Medical History (Required):

Are you currently under the care of a physician?
Have you had any recent surgeries?
Do you have any types of metal plates, pins, mesh, etc.?
Do you have a pacemaker or other implantable device?
Do you have any of the following conditions?
Are you pregnant or trying to become pregnant?
Are you breastfeeding?
Do you have any of the following allergies? (Check all that apply)
Are you currently taking any of the following medications? (Check all that apply)
Are you taking herbal preparations or vitamins? (St. John’s Wort, Vitamin E, Turmeric, Fish Oil etc.)
Do you smoke?
Are you planning a vacation in the sun in the next 3 months?

By submitting this form, you  agree that: You have answered the questions in this questionnaire to the best of your knowledge, you understand that it is your responsibility to inform your clinician of your current health conditions while seeking treatment as a patient; and you agree to  update this information as it occurs or if there are any changes to your health or medications in between treatments.

Thank you! Your submission has been received!
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