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New Patient Consultation Form

Cancellation Policy

It is our policy to require a 24 hour notice of cancellation for your scheduled appointment. In the event that you cancel your appointment with less than a 24 hour notice, we will access a cancellation fee of $100.00.

Today's date: May 30, 2026

First Patient’s Name
First Name*
Last Name*
Phone*
First Patient’s Date of Birth*
Date of Birth
Information
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Have you ever had any of the following conditions? (check all that apply)
asthma
allergy/hay fever
anemia
arthritis/rheumatism
back problems
blood disease
cancer
chemotherapy
diabetes
epilepsy
eye injury or disease
headaches/migraines
heart disease
head injury
hepatitis
herpes
high blood pressure
HIV
infection (active)
kidney disease
lupus
melanoma
mitral valve prolapse
nervousness
radiation treatment
respiratory problems
shingles/past outbreak
skin conditions
sinus problems
stroke
swollen feet/ankles
thyroid problems
tuberculosis
ulcers
varicose veins

Allergies (medications, cosmetics, latex/other):

List all current medications/supplements:

List current skin care regimen:


AM:

PM:

Have you ever had/are currently using:

Retin-A or retinal *
No
Yes
Prescription acne medication*
No
Yes
Accutane*
No
Yes
Steroids*
No
Yes
Birth control*
No
Yes
Pregnant/Lactating?*
No
Yes
If yes, due:

Previous Cosmetic Facial Treatments:

Chemical Peel*
No
Yes
Botox®*
No
Yes
Dermal Fillers*
No
Yes
Tattoo/Perm Makeup*
No
Yes
Facial Surgery*
No
Yes
Laser Treatments*
No
Yes
Tanning (last 2wks)*
No
Yes

Your personal skin Type Evaluation: (check all that apply) 

Skin Type:
Normal
Oily
Dry
Combination
Other
Condition:
Texture
Sun Damage
Acne/Oily
Pigmented
Other
Sunburn Sensitivity:
Always
Usually
Occasionally
Rarely
Never

Specific areas of concern:
What Medical Aesthetic Treatments are you interested in?
BBL/IPL
Botox
Filler
Chemical Peels
CoolPeel
Hydrafacial
Laser Hair Reduction
Laser Treatments
Microneedling/SkinPen
First Patient’s Signature*
Second Patient’s Name
First Name*
Last Name*
Patient’s Date of Birth*
Date of Birth
Information
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Have you ever had any of the following conditions? (check all that apply)
asthma
allergy/hay fever
anemia
arthritis/rheumatism
back problems
blood disease
cancer
chemotherapy
diabetes
epilepsy
eye injury or disease
headaches/migraines
heart disease
head injury
hepatitis
herpes
high blood pressure
HIV
infection (active)
kidney disease
lupus
melanoma
mitral valve prolapse
nervousness
radiation treatment
respiratory problems
shingles/past outbreak
skin conditions
sinus problems
stroke
swollen feet/ankles
thyroid problems
tuberculosis
ulcers
varicose veins

Allergies (medications, cosmetics, latex/other):

List all current medications/supplements:

List current skin care regimen:


AM:

PM:

Have you ever had/are currently using:

Retin-A or retinal *
No
Yes
Prescription acne medication*
No
Yes
Accutane*
No
Yes
Steroids*
No
Yes
Birth control*
No
Yes
Pregnant/Lactating?*
No
Yes
If yes, due:

Previous Cosmetic Facial Treatments:

Chemical Peel*
No
Yes
Botox®*
No
Yes
Dermal Fillers*
No
Yes
Tattoo/Perm Makeup*
No
Yes
Facial Surgery*
No
Yes
Laser Treatments*
No
Yes
Tanning (last 2wks)*
No
Yes

Your personal skin Type Evaluation: (check all that apply) 

Skin Type:
Normal
Oily
Dry
Combination
Other
Condition:
Texture
Sun Damage
Acne/Oily
Pigmented
Other
Sunburn Sensitivity:
Always
Usually
Occasionally
Rarely
Never

Specific areas of concern:
What Medical Aesthetic Treatments are you interested in?
BBL/IPL
Botox
Filler
Chemical Peels
CoolPeel
Hydrafacial
Laser Hair Reduction
Laser Treatments
Microneedling/SkinPen
Third Patient’s Name
First Name*
Last Name*
Patient’s Date of Birth*
Date of Birth
Information
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Have you ever had any of the following conditions? (check all that apply)
asthma
allergy/hay fever
anemia
arthritis/rheumatism
back problems
blood disease
cancer
chemotherapy
diabetes
epilepsy
eye injury or disease
headaches/migraines
heart disease
head injury
hepatitis
herpes
high blood pressure
HIV
infection (active)
kidney disease
lupus
melanoma
mitral valve prolapse
nervousness
radiation treatment
respiratory problems
shingles/past outbreak
skin conditions
sinus problems
stroke
swollen feet/ankles
thyroid problems
tuberculosis
ulcers
varicose veins

Allergies (medications, cosmetics, latex/other):

List all current medications/supplements:

List current skin care regimen:


AM:

PM:

Have you ever had/are currently using:

Retin-A or retinal *
No
Yes
Prescription acne medication*
No
Yes
Accutane*
No
Yes
Steroids*
No
Yes
Birth control*
No
Yes
Pregnant/Lactating?*
No
Yes
If yes, due:

Previous Cosmetic Facial Treatments:

Chemical Peel*
No
Yes
Botox®*
No
Yes
Dermal Fillers*
No
Yes
Tattoo/Perm Makeup*
No
Yes
Facial Surgery*
No
Yes
Laser Treatments*
No
Yes
Tanning (last 2wks)*
No
Yes

Your personal skin Type Evaluation: (check all that apply) 

Skin Type:
Normal
Oily
Dry
Combination
Other
Condition:
Texture
Sun Damage
Acne/Oily
Pigmented
Other
Sunburn Sensitivity:
Always
Usually
Occasionally
Rarely
Never

Specific areas of concern:
What Medical Aesthetic Treatments are you interested in?
BBL/IPL
Botox
Filler
Chemical Peels
CoolPeel
Hydrafacial
Laser Hair Reduction
Laser Treatments
Microneedling/SkinPen
Fourth Patient’s Name
First Name*
Last Name*
Patient’s Date of Birth*
Date of Birth
Information
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Have you ever had any of the following conditions? (check all that apply)
asthma
allergy/hay fever
anemia
arthritis/rheumatism
back problems
blood disease
cancer
chemotherapy
diabetes
epilepsy
eye injury or disease
headaches/migraines
heart disease
head injury
hepatitis
herpes
high blood pressure
HIV
infection (active)
kidney disease
lupus
melanoma
mitral valve prolapse
nervousness
radiation treatment
respiratory problems
shingles/past outbreak
skin conditions
sinus problems
stroke
swollen feet/ankles
thyroid problems
tuberculosis
ulcers
varicose veins

Allergies (medications, cosmetics, latex/other):

List all current medications/supplements:

List current skin care regimen:


AM:

PM:

Have you ever had/are currently using:

Retin-A or retinal *
No
Yes
Prescription acne medication*
No
Yes
Accutane*
No
Yes
Steroids*
No
Yes
Birth control*
No
Yes
Pregnant/Lactating?*
No
Yes
If yes, due:

Previous Cosmetic Facial Treatments:

Chemical Peel*
No
Yes
Botox®*
No
Yes
Dermal Fillers*
No
Yes
Tattoo/Perm Makeup*
No
Yes
Facial Surgery*
No
Yes
Laser Treatments*
No
Yes
Tanning (last 2wks)*
No
Yes

Your personal skin Type Evaluation: (check all that apply) 

Skin Type:
Normal
Oily
Dry
Combination
Other
Condition:
Texture
Sun Damage
Acne/Oily
Pigmented
Other
Sunburn Sensitivity:
Always
Usually
Occasionally
Rarely
Never

Specific areas of concern:
What Medical Aesthetic Treatments are you interested in?
BBL/IPL
Botox
Filler
Chemical Peels
CoolPeel
Hydrafacial
Laser Hair Reduction
Laser Treatments
Microneedling/SkinPen
Fifth Patient’s Name
First Name*
Last Name*
Patient’s Date of Birth*
Date of Birth
Information
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Have you ever had any of the following conditions? (check all that apply)
asthma
allergy/hay fever
anemia
arthritis/rheumatism
back problems
blood disease
cancer
chemotherapy
diabetes
epilepsy
eye injury or disease
headaches/migraines
heart disease
head injury
hepatitis
herpes
high blood pressure
HIV
infection (active)
kidney disease
lupus
melanoma
mitral valve prolapse
nervousness
radiation treatment
respiratory problems
shingles/past outbreak
skin conditions
sinus problems
stroke
swollen feet/ankles
thyroid problems
tuberculosis
ulcers
varicose veins

Allergies (medications, cosmetics, latex/other):

List all current medications/supplements:

List current skin care regimen:


AM:

PM:

Have you ever had/are currently using:

Retin-A or retinal *
No
Yes
Prescription acne medication*
No
Yes
Accutane*
No
Yes
Steroids*
No
Yes
Birth control*
No
Yes
Pregnant/Lactating?*
No
Yes
If yes, due:

Previous Cosmetic Facial Treatments:

Chemical Peel*
No
Yes
Botox®*
No
Yes
Dermal Fillers*
No
Yes
Tattoo/Perm Makeup*
No
Yes
Facial Surgery*
No
Yes
Laser Treatments*
No
Yes
Tanning (last 2wks)*
No
Yes

Your personal skin Type Evaluation: (check all that apply) 

Skin Type:
Normal
Oily
Dry
Combination
Other
Condition:
Texture
Sun Damage
Acne/Oily
Pigmented
Other
Sunburn Sensitivity:
Always
Usually
Occasionally
Rarely
Never

Specific areas of concern:
What Medical Aesthetic Treatments are you interested in?
BBL/IPL
Botox
Filler
Chemical Peels
CoolPeel
Hydrafacial
Laser Hair Reduction
Laser Treatments
Microneedling/SkinPen
Sixth Patient’s Name
First Name*
Last Name*
Patient’s Date of Birth*
Date of Birth
Information
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Have you ever had any of the following conditions? (check all that apply)
asthma
allergy/hay fever
anemia
arthritis/rheumatism
back problems
blood disease
cancer
chemotherapy
diabetes
epilepsy
eye injury or disease
headaches/migraines
heart disease
head injury
hepatitis
herpes
high blood pressure
HIV
infection (active)
kidney disease
lupus
melanoma
mitral valve prolapse
nervousness
radiation treatment
respiratory problems
shingles/past outbreak
skin conditions
sinus problems
stroke
swollen feet/ankles
thyroid problems
tuberculosis
ulcers
varicose veins

Allergies (medications, cosmetics, latex/other):

List all current medications/supplements:

List current skin care regimen:


AM:

PM:

Have you ever had/are currently using:

Retin-A or retinal *
No
Yes
Prescription acne medication*
No
Yes
Accutane*
No
Yes
Steroids*
No
Yes
Birth control*
No
Yes
Pregnant/Lactating?*
No
Yes
If yes, due:

Previous Cosmetic Facial Treatments:

Chemical Peel*
No
Yes
Botox®*
No
Yes
Dermal Fillers*
No
Yes
Tattoo/Perm Makeup*
No
Yes
Facial Surgery*
No
Yes
Laser Treatments*
No
Yes
Tanning (last 2wks)*
No
Yes

Your personal skin Type Evaluation: (check all that apply) 

Skin Type:
Normal
Oily
Dry
Combination
Other
Condition:
Texture
Sun Damage
Acne/Oily
Pigmented
Other
Sunburn Sensitivity:
Always
Usually
Occasionally
Rarely
Never

Specific areas of concern:
What Medical Aesthetic Treatments are you interested in?
BBL/IPL
Botox
Filler
Chemical Peels
CoolPeel
Hydrafacial
Laser Hair Reduction
Laser Treatments
Microneedling/SkinPen
Seventh Patient’s Name
First Name*
Last Name*
Patient’s Date of Birth*
Date of Birth
Information
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Have you ever had any of the following conditions? (check all that apply)
asthma
allergy/hay fever
anemia
arthritis/rheumatism
back problems
blood disease
cancer
chemotherapy
diabetes
epilepsy
eye injury or disease
headaches/migraines
heart disease
head injury
hepatitis
herpes
high blood pressure
HIV
infection (active)
kidney disease
lupus
melanoma
mitral valve prolapse
nervousness
radiation treatment
respiratory problems
shingles/past outbreak
skin conditions
sinus problems
stroke
swollen feet/ankles
thyroid problems
tuberculosis
ulcers
varicose veins

Allergies (medications, cosmetics, latex/other):

List all current medications/supplements:

List current skin care regimen:


AM:

PM:

Have you ever had/are currently using:

Retin-A or retinal *
No
Yes
Prescription acne medication*
No
Yes
Accutane*
No
Yes
Steroids*
No
Yes
Birth control*
No
Yes
Pregnant/Lactating?*
No
Yes
If yes, due:

Previous Cosmetic Facial Treatments:

Chemical Peel*
No
Yes
Botox®*
No
Yes
Dermal Fillers*
No
Yes
Tattoo/Perm Makeup*
No
Yes
Facial Surgery*
No
Yes
Laser Treatments*
No
Yes
Tanning (last 2wks)*
No
Yes

Your personal skin Type Evaluation: (check all that apply) 

Skin Type:
Normal
Oily
Dry
Combination
Other
Condition:
Texture
Sun Damage
Acne/Oily
Pigmented
Other
Sunburn Sensitivity:
Always
Usually
Occasionally
Rarely
Never

Specific areas of concern:
What Medical Aesthetic Treatments are you interested in?
BBL/IPL
Botox
Filler
Chemical Peels
CoolPeel
Hydrafacial
Laser Hair Reduction
Laser Treatments
Microneedling/SkinPen
Eighth Patient’s Name
First Name*
Last Name*
Patient’s Date of Birth*
Date of Birth
Information
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Have you ever had any of the following conditions? (check all that apply)
asthma
allergy/hay fever
anemia
arthritis/rheumatism
back problems
blood disease
cancer
chemotherapy
diabetes
epilepsy
eye injury or disease
headaches/migraines
heart disease
head injury
hepatitis
herpes
high blood pressure
HIV
infection (active)
kidney disease
lupus
melanoma
mitral valve prolapse
nervousness
radiation treatment
respiratory problems
shingles/past outbreak
skin conditions
sinus problems
stroke
swollen feet/ankles
thyroid problems
tuberculosis
ulcers
varicose veins

Allergies (medications, cosmetics, latex/other):

List all current medications/supplements:

List current skin care regimen:


AM:

PM:

Have you ever had/are currently using:

Retin-A or retinal *
No
Yes
Prescription acne medication*
No
Yes
Accutane*
No
Yes
Steroids*
No
Yes
Birth control*
No
Yes
Pregnant/Lactating?*
No
Yes
If yes, due:

Previous Cosmetic Facial Treatments:

Chemical Peel*
No
Yes
Botox®*
No
Yes
Dermal Fillers*
No
Yes
Tattoo/Perm Makeup*
No
Yes
Facial Surgery*
No
Yes
Laser Treatments*
No
Yes
Tanning (last 2wks)*
No
Yes

Your personal skin Type Evaluation: (check all that apply) 

Skin Type:
Normal
Oily
Dry
Combination
Other
Condition:
Texture
Sun Damage
Acne/Oily
Pigmented
Other
Sunburn Sensitivity:
Always
Usually
Occasionally
Rarely
Never

Specific areas of concern:
What Medical Aesthetic Treatments are you interested in?
BBL/IPL
Botox
Filler
Chemical Peels
CoolPeel
Hydrafacial
Laser Hair Reduction
Laser Treatments
Microneedling/SkinPen
Ninth Patient’s Name
First Name*
Last Name*
Patient’s Date of Birth*
Date of Birth
Information
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Have you ever had any of the following conditions? (check all that apply)
asthma
allergy/hay fever
anemia
arthritis/rheumatism
back problems
blood disease
cancer
chemotherapy
diabetes
epilepsy
eye injury or disease
headaches/migraines
heart disease
head injury
hepatitis
herpes
high blood pressure
HIV
infection (active)
kidney disease
lupus
melanoma
mitral valve prolapse
nervousness
radiation treatment
respiratory problems
shingles/past outbreak
skin conditions
sinus problems
stroke
swollen feet/ankles
thyroid problems
tuberculosis
ulcers
varicose veins

Allergies (medications, cosmetics, latex/other):

List all current medications/supplements:

List current skin care regimen:


AM:

PM:

Have you ever had/are currently using:

Retin-A or retinal *
No
Yes
Prescription acne medication*
No
Yes
Accutane*
No
Yes
Steroids*
No
Yes
Birth control*
No
Yes
Pregnant/Lactating?*
No
Yes
If yes, due:

Previous Cosmetic Facial Treatments:

Chemical Peel*
No
Yes
Botox®*
No
Yes
Dermal Fillers*
No
Yes
Tattoo/Perm Makeup*
No
Yes
Facial Surgery*
No
Yes
Laser Treatments*
No
Yes
Tanning (last 2wks)*
No
Yes

Your personal skin Type Evaluation: (check all that apply) 

Skin Type:
Normal
Oily
Dry
Combination
Other
Condition:
Texture
Sun Damage
Acne/Oily
Pigmented
Other
Sunburn Sensitivity:
Always
Usually
Occasionally
Rarely
Never

Specific areas of concern:
What Medical Aesthetic Treatments are you interested in?
BBL/IPL
Botox
Filler
Chemical Peels
CoolPeel
Hydrafacial
Laser Hair Reduction
Laser Treatments
Microneedling/SkinPen
Tenth Patient’s Name
First Name*
Last Name*
Patient’s Date of Birth*
Date of Birth
Information
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Have you ever had any of the following conditions? (check all that apply)
asthma
allergy/hay fever
anemia
arthritis/rheumatism
back problems
blood disease
cancer
chemotherapy
diabetes
epilepsy
eye injury or disease
headaches/migraines
heart disease
head injury
hepatitis
herpes
high blood pressure
HIV
infection (active)
kidney disease
lupus
melanoma
mitral valve prolapse
nervousness
radiation treatment
respiratory problems
shingles/past outbreak
skin conditions
sinus problems
stroke
swollen feet/ankles
thyroid problems
tuberculosis
ulcers
varicose veins

Allergies (medications, cosmetics, latex/other):

List all current medications/supplements:

List current skin care regimen:


AM:

PM:

Have you ever had/are currently using:

Retin-A or retinal *
No
Yes
Prescription acne medication*
No
Yes
Accutane*
No
Yes
Steroids*
No
Yes
Birth control*
No
Yes
Pregnant/Lactating?*
No
Yes
If yes, due:

Previous Cosmetic Facial Treatments:

Chemical Peel*
No
Yes
Botox®*
No
Yes
Dermal Fillers*
No
Yes
Tattoo/Perm Makeup*
No
Yes
Facial Surgery*
No
Yes
Laser Treatments*
No
Yes
Tanning (last 2wks)*
No
Yes

Your personal skin Type Evaluation: (check all that apply) 

Skin Type:
Normal
Oily
Dry
Combination
Other
Condition:
Texture
Sun Damage
Acne/Oily
Pigmented
Other
Sunburn Sensitivity:
Always
Usually
Occasionally
Rarely
Never

Specific areas of concern:
What Medical Aesthetic Treatments are you interested in?
BBL/IPL
Botox
Filler
Chemical Peels
CoolPeel
Hydrafacial
Laser Hair Reduction
Laser Treatments
Microneedling/SkinPen
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and offers by e-mail.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Photo/Video Consent
I understand Restorative Skincare may take photos and/or videos of patients to be used for educational and/or marketing purposes (I.e. social media, website, e-newsletters, etc.) I acknowledge that these materials will remain the property of Restorative Skincare and I waive all rights to the above stated materials. Please Select:
I DO grant permission for Restorative Skincare to use these materials.
I DO NOT grant permission for Restorative Skincare to use these materials.
Hippa Acknowledgement
To our patients: This notice describes how health information about you, as a patient, may be used and disclosed, and how you can get access to your health information. This notice is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Our commitment to your privacy: Our medical spa is dedicated to maintaining the privacy of your health information. We are also required by Federal law to maintain the confidentiality of your health information. Although these laws are complicated, all medical providers are required to provide you with the following important information: The HIPAA law permits the use and disclosure of personally-identifiable health information as needed for diagnosis, treatment, or billing of health care services, provided that any such disclosure must be limited to the minimum necessary information to accomplish these purposes, and only to properly qualified persons. Special safeguards must be maintained to minimize any chance of inadvertent disclosure of personally-identifiable health information to unauthorized persons, particularly of especially sensitive information. We are committed to maintaining the security and privacy of all information (including billing information) contained in our medical records. Use and disclosure of your health information in certain special circumstances: The following additional circumstances may also require us to use or disclose your health information: 1. To public health authorities and health oversight agencies that are authorized by law to collect such information. 2. Lawsuits and similar proceedings in response to a court or administrative order. 3. If required to do so by a law enforcement official. 4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make the disclosures to a person or organization able to help prevent the threat. 5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 6. To federal officials for intelligence and national security activities authorized by law. 7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. 8. For Workers Compensation and similar programs. 9. In order to avert a serious threat to the health and safety of you or any other person pursuant to applicable law. Your rights regarding your health information: 1. Communications. You can request that our medical spa communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather than work. We will accommodate reasonable requests. 2. You can request a restriction in our use or disclosure of your health information for treatment or payment. 3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you. 4. You may ask to amend your health information if you believe it is incorrect or incomplete. To request an amendment, your request must be made in writing and submitted to Restorative Skincare Med Spa & Laser Center. Please provide a reason that supports your request for amendment. 5. Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask for a copy of this Notice at any time. To obtain an additional copy of this notice, please contact the office manager. 6. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our office or with the US Department of Health and Human Services. To file a complaint with our office, please contact the office manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint. 7. Right to provide an authorization for other uses and disclosures. Our office will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. If you have any questions regarding this notice or our health information privacy policies, please contact Restorative Skincare Med Spa & Laser Center office at (404)-341-4775*
I acknowledge
I do not acknowledge
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Address Line 1 *
Address Line 2
City *
State *
Zip Code *
Have you ever had any of the following conditions? (check all that apply)
asthma
allergy/hay fever
anemia
arthritis/rheumatism
back problems
blood disease
cancer
chemotherapy
diabetes
epilepsy
eye injury or disease
headaches/migraines
heart disease
head injury
hepatitis
herpes
high blood pressure
HIV
infection (active)
kidney disease
lupus
melanoma
mitral valve prolapse
nervousness
radiation treatment
respiratory problems
shingles/past outbreak
skin conditions
sinus problems
stroke
swollen feet/ankles
thyroid problems
tuberculosis
ulcers
varicose veins

Allergies (medications, cosmetics, latex/other):

List all current medications/supplements:

List current skin care regimen:


AM:

PM:

Have you ever had/are currently using:

Retin-A or retinal *
No
Yes
Prescription acne medication*
No
Yes
Accutane*
No
Yes
Steroids*
No
Yes
Birth control*
No
Yes
Pregnant/Lactating?*
No
Yes
If yes, due:

Previous Cosmetic Facial Treatments:

Chemical Peel*
No
Yes
Botox®*
No
Yes
Dermal Fillers*
No
Yes
Tattoo/Perm Makeup*
No
Yes
Facial Surgery*
No
Yes
Laser Treatments*
No
Yes
Tanning (last 2wks)*
No
Yes

Your personal skin Type Evaluation: (check all that apply) 

Skin Type:
Normal
Oily
Dry
Combination
Other
Condition:
Texture
Sun Damage
Acne/Oily
Pigmented
Other
Sunburn Sensitivity:
Always
Usually
Occasionally
Rarely
Never

Specific areas of concern:
What Medical Aesthetic Treatments are you interested in?
BBL/IPL
Botox
Filler
Chemical Peels
CoolPeel
Hydrafacial
Laser Hair Reduction
Laser Treatments
Microneedling/SkinPen
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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