Patient Information Sheet


Sex:

How do you prefer to receive appointment confirmations?

Medical History


Are you receiving care from other health care professionals?

Allergies:

Previous Procedures (if YES list date/area):

Chemical Peel

Injectables/Fillers

Tattoo/Permanent Makeup

Waxing/Hair Removal

Facial Surgery

Laser Surgery

Microdermabrasion

Lesion/Mole Removal

Superficial Metal or other Implants

Microneedling

Do you or have you ever had any of the following conditions? Check all that apply:

AIDS/HIV

Anemia

Arthritis

Auto Immune Disorder

Asthma

Bleeding Disorder

Blood Disease

Blood Transfusion

Cancer (Chemo/Radiation)

Diabetes

Dizziness

Epilepsy/Seizures

Eczema

Fainting

Hay Fever

Heart Disease

Hepatitis

High Blood Pressure

Infection (active)

Keloid/Hypertrophic Scars

Kidney Disease

Liver Disease

Melanoma

Mental Disorder

Neuromuscular Disorder

Photosensitive Conditions

Pigmentation Disorder

Porphyria

Psoriasis

Respiratory Issues

Skin Disease

Skin Cancer

Sinus Problems

Stomach Problems

Stroke

Thyroid Disease

Other

Have you ever had:

Cold Sores/Herpes/Fever Blisters/Shingles

frequency:

Have you ever or are currently using:

Retin-A, Renova, Retinoic Acid Products

Steroids

Roaccutane(Accutane), Isotretinoin, Sotret, Claravis, Amnesteen, Absorica, Epuris, Isotroin

Pacemaker/Internal Defibrillator

Prescription Acne Medication

Radiation Treatment

Birth Control Pills

Chemotherapy

Are you Currently:

Pregnant

Breastfeeding

Trying to become Pregnant

Tan/using self-tanners

Taking Aspirin or Blood Thinners