New Patient Form For Cosmetic Injectables 123456 Patient Information Sheet Patient Name:* Today’s date:* MM slash DD slash YYYY Date of Birth:* MM slash DD slash YYYY Sex:* Male Female Address* 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 Call Text Message Email How did you hear about us?* Medical History Are you receiving care from other health care professionals? Yes No If 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 Peel Yes No Injectables/Fillers Yes No Tattoo/Permanent Makeup Yes No Waxing/Hair Removal Yes No Facial Surgery Yes No Microdermabrasion Yes No Lesion/Mole Removal Yes No Superficial Metal or other Implants Yes No Microneedling Yes No Lesion/Mole Removal Yes No Do you or have you ever had any of the following conditions? Check all that apply:AIDS/HIV Yes No Anemia Yes No Arthritis Yes No Auto Immune Disorder Yes No Asthma Yes No Bleeding Disorder Yes No Blood Disease Yes No Blood Transfusion Yes No Cancer (Chemo/Radiation) Yes No Diabetes Yes No Dizziness Yes No Epilepsy/Seizures Yes No Eczema Yes No Fainting Yes No Hay Fever Yes No Heart Disease Yes No Hepatitis Yes No High Blood Pressure Yes No Infection (active) Yes No Keloid/Hypertrophic Scars Yes No Kidney Disease Yes No Liver Disease Yes No Melanoma Yes No Mental Disorder Yes No Neuromuscular Disorder Yes No Photosensitive Conditions Yes No Pigmentation Disorder Yes No Porphyria Yes No Psoriasis Yes No Respiratory Issues Yes No Skin Disease Yes No Skin Cancer Yes No Sinus Problems Yes No Stomach Problems Yes No Stroke Yes No Thyroid Disease Yes No Other Yes No Have you ever had: Cold Sores/Herpes/Fever Blisters/Shingles Yes No Have you ever or are currently using: Retin-A, Renova, Retinoic Acid Products Yes No Steroids Yes No Roaccutane(Accutane), Isotretinoin, Sotret, Claravis, Amnesteen, Absorica, Epuris, Isotroin Yes No Pacemaker/Internal Defibrillator Yes No Prescription Acne Medication Yes No Radiation Treatment Yes No Birth Control Pills Yes No Chemotherapy Yes No Are you Currently: Pregnant Yes No Breastfeeding Yes No Trying to become Pregnant Yes No Tan/using self-tanners Yes No Taking Aspirin or Blood Thinners Yes No Untitled* The above information is accurate to the best of my knowledge.
