HomePatient formsNew patient form New patient form Patient Information Sheet Patient Name: Today’s date: Date of Birth: Age: Sex: MaleFemale Address: City: State: Zip: Cell Phone #: Occupation: Email Address: Emergency contact: Name Relationship: Phone #: How do you prefer to receive appointment confirmations? Phone CallText MessageEmail How did you hear about us? Medical History Are you receiving care from other health care professionals? YesNo 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: Allergies: Medication Allergies: Cosmetic Allergies: Latex/Other Allergies: Previous Procedures (if YES list date/area): Chemical Peel YesNo Injectables/Fillers YesNo Tattoo/Permanent Makeup YesNo Waxing/Hair Removal YesNo Facial Surgery YesNo Laser Surgery YesNo Microdermabrasion YesNo Lesion/Mole Removal YesNo Superficial Metal or other Implants YesNo Microneedling YesNo Do you or have you ever had any of the following conditions? Check all that apply: AIDS/HIV YesNo Anemia YesNo Arthritis YesNo Auto Immune Disorder YesNo Asthma YesNo Bleeding Disorder YesNo Blood Disease YesNo Blood Transfusion YesNo Cancer (Chemo/Radiation) YesNo Diabetes YesNo Dizziness YesNo Epilepsy/Seizures YesNo Eczema YesNo Fainting YesNo Hay Fever YesNo Heart Disease YesNo Hepatitis YesNo High Blood Pressure YesNo Infection (active) YesNo Keloid/Hypertrophic Scars YesNo Kidney Disease YesNo Liver Disease YesNo Melanoma YesNo Mental Disorder YesNo Neuromuscular Disorder YesNo Photosensitive Conditions YesNo Pigmentation Disorder YesNo Porphyria YesNo Psoriasis YesNo Respiratory Issues YesNo Skin Disease YesNo Skin Cancer YesNo Sinus Problems YesNo Stomach Problems YesNo Stroke YesNo Thyroid Disease YesNo Other YesNo Have you ever had: Cold Sores/Herpes/Fever Blisters/Shingles YesNo frequency: 1/year1-3/year3-5+/year Have you ever or are currently using: Retin-A, Renova, Retinoic Acid Products YesNo Steroids YesNo Roaccutane(Accutane), Isotretinoin, Sotret, Claravis, Amnesteen, Absorica, Epuris, Isotroin YesNo Pacemaker/Internal Defibrillator YesNo Prescription Acne Medication YesNo Radiation Treatment YesNo Birth Control Pills YesNo Chemotherapy YesNo Are you Currently: Pregnant YesNo Due date: Breastfeeding YesNo Trying to become Pregnant YesNo Tan/using self-tanners YesNo Taking Aspirin or Blood Thinners YesNo The above information is accurate to the best of my knowledge.