New Patient Form For Cosmetic Injectables 1 2 3 4 5 6 Patient Information Sheet Patient Name:*Today’s date:* Date Format: MM slash DD slash YYYY Date of Birth:* Date Format: MM slash DD slash YYYY Sex:*MaleFemaleAddress*City:* City State:* State Zip: ZIP Cell Phone :*Occupation:Email Address:* Emergency contact name:*Emergency contact Relationship:*Emergency contact Phone :*How do you prefer to receive appointment confirmations?*Phone CallText MessageEmailHow did you hear about us?* Medical History Are you receiving care from other health care professionals?YesNoIf yes, please name them and their specialty:Please list any drugs or medications you are taking: Please list any vitamins/herbs/homeopathies/other you are taking: Medication Allergies:Cosmetic Allergies:Latex/Other Allergies: Previous Procedures if YES list date/areaChemical PeelYesNoInjectables/FillersYesNoTattoo/Permanent MakeupYesNoWaxing/Hair RemovalYesNoFacial SurgeryYesNoMicrodermabrasionYesNoLesion/Mole RemovalYesNoSuperficial Metal or other ImplantsYesNoMicroneedlingYesNoLesion/Mole RemovalYesNo Do you or have you ever had any of the following conditions? Check all that apply:AIDS/HIVYesNoAnemiaYesNoArthritisYesNoAuto Immune DisorderYesNoAsthmaYesNoBleeding DisorderYesNoBlood DiseaseYesNoBlood TransfusionYesNoCancer (Chemo/Radiation)YesNoDiabetesYesNoDizzinessYesNoEpilepsy/SeizuresYesNoEczemaYesNoFaintingYesNoHay FeverYesNoHeart DiseaseYesNoHepatitisYesNoHigh Blood PressureYesNoInfection (active)YesNoKeloid/Hypertrophic ScarsYesNoKidney DiseaseYesNoLiver DiseaseYesNoMelanomaYesNoMental DisorderYesNoNeuromuscular DisorderYesNoPhotosensitive ConditionsYesNoPigmentation DisorderYesNoPorphyriaYesNoPsoriasisYesNoRespiratory IssuesYesNoSkin DiseaseYesNoSkin CancerYesNoSinus ProblemsYesNoStomach ProblemsYesNoStrokeYesNoThyroid DiseaseYesNoOtherYesNo Have you ever had: Cold Sores/Herpes/Fever Blisters/ShinglesYesNoHave you ever or are currently using: Retin-A, Renova, Retinoic Acid ProductsYesNoSteroidsYesNoRoaccutane(Accutane), Isotretinoin, Sotret, Claravis, Amnesteen, Absorica, Epuris, IsotroinYesNoPacemaker/Internal DefibrillatorYesNoPrescription Acne MedicationYesNoRadiation TreatmentYesNoBirth Control PillsYesNoChemotherapyYesNo Are you Currently: PregnantYesNoBreastfeedingYesNoTrying to become PregnantYesNoTan/using self-tannersYesNoTaking Aspirin or Blood ThinnersYesNoUntitled* The above information is accurate to the best of my knowledge. This iframe contains the logic required to handle Ajax powered Gravity Forms.