Patient Information Form

HIPPA PRIVACY NOTICE:
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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?

Web SearchSocial MediaPatient Referral

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?

YesNo

Are you currently taking medication for any skin condition?

YesNo

Are you currently taking or have you ever taken any of the following:

AccutaneRetin-AHydroquinone or Bleaching Agent

Do you get cold sores or fever blisters?

YesNo

Do you form thick or raised scars (Keloid)?

YesNo

Do you develop hyperpigmentation or dark spots?

YesNo

When were you last exposed to sun or tanning booth?

Do you use self-tanning products?

YesNo

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?

YesNo

Have you had any recent surgeries?

YesNo

Do you have any of the following conditions?

Do you have any types of metal plates, pins, mesh, etc.?

YesNo

Do you have a pacemaker or other implantable device?

YesNo

Are you pregnant or trying to become pregnant?

YesNo

Are you breastfeeding?

YesNo

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.)

YesNo

Do you smoke?

YesNo

Are you planning a vacation in the sun in the next 3 months?

YesNo

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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Patient Information Form