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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: February 22, 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.
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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