Contact Information:
Name:
Email:
Address:
City:
State:
AK-Alaska
AL-Alabama
AR-Arkansas
AZ-Arizona
CA-California
CO-Colorado
CT-Connecticut
DC-District of Columbia
DE-Delaware
FL-Florida
GA-Georgia
HI-Hawaii
IA-Iowa
ID-Idaho
IL-Illinois
IN-Indiana
KS-Kansas
KY-Kentucky
LA-Louisiana
MA-Massachusetts
MD-Maryland
ME-Maine
MI-Michigan
MN-Minnesota
MO-Missouri
MS-Mississippi
MT-Montana
NC-North Carolina
ND-North Dakota
NE-Nebraska
NH-New Hampshire
NJ-New Jersey
NM-New Mexico
NV-Nevada
NY-New York
OH-Ohio
OK-Oklahoma
OR-Oregon
OT-Other
PA-Pennsylvania
RI-Rhode Island
SC-South Carolina
SD-South Dakota
TN-Tennessee
TX-Texas
UT-Utah
VA-Virginia
VT-Vermont
WA-Washington
WI-Wisconsin
WV-West Virginia
WY-Wyoming
Zip Code:
Phone Number
Work Phone Number
Cell Phone Number
Date of Birth
Gender
Select
Female
Male
What concerns would you like to have addressed (please fill all that apply):
Age Spots located on my
Unwanted Hair located on my
Redness located on my
Veins located on my
Acne Scars located on my
Stretch Marks located on my
Active Acne located on my
Wrinkles or Lines located on my
Background Information:
Your Ethnicity:
Mother’s Ethnicity:
Father’s Ethnicity:
Are you tan?
Do you tan artificially?
If yes, how?
When was the last time you had a significant amount of sun exposure?
List any ongoing heath and skin conditions:
List any drugs you are allergic to:
Do you or does anyone in your family have a history of seizures?
In the past 3 months have you used Retin-A?
If so, for how long?
In the past 3 months have you used Renova?
If so, for how long?
In the past 3 months have you used Differin?
If so, for how long?
Are you currently using Accutane?
If so, for how long?
List any oral/topical antibiotic you use, including how long you have used them:
Do you take birth control or hormone replacement?
If so, which ones?
What other medications do you take, if any?
Check those you are sensitive/allergic to:
Which best describes your skin type?
Does your skin break out?
How would you describe your skin?
Do you spend a lot of time outdoors?
Do you wear sunscreen?
Do you go to tanning booths?
Have you, or do you smoke?
If so, for how long?
Have you had electrolysis, waxing, or laser hair removal?
If so, were you pleased with the results?
Have you ever had permanent make-up or tattoo?
Have you ever had injections/implants such as Artecoll, Collagen, Radiesse, Restylane, Perlane, Goretex or Silicone in the areas you are considering having treatment?
Are you currently having Microdermabrasion, chemical peels, collagen injections or Botox?
If so, which and when was the last treatment?
Are you pregnant?
Are you planning on becoming pregnant?
Are you currently breastfeeding?
Have you had any facial surgery?
If so, what and when?
Have you had any cosmetic peels?
If so, what and when?
Have you ever had laser vein removal?
If so, when?
Have you ever had Sclerotherapy?
Please list the brand names of products you currently use:
Cleanser:
Toner:
Moisturizer:
Scrub / Mask:
Sunscreen:
Makeup:
Other:
