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Aesthetic Clinic and Medical Spa DC
GLOWING SKIN RENEWAL.
BOTOX CLINIC DC
CUSTOM CHEMICAL PEEL
LASER HAIR REMOVAL
Laser Hair removal Protocols
LASER SKIN RESURFACING
BLUE LED THERAPY
RED LED THERAPY
RF Skin Tightening
HIFU Skin Tightening
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Acne Program Gallery
Dermal Infusion gallery
Lightwave LED Gallery
Laser Hair Removal gallery
SkinPen Microneedling Gallery
Vi Peel Gallery
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New Patient Forms
Medical Intake Form
How did you hear about us?*:
Check all Medical Conditions:
High Blood Pressure
Ulcers or Bleeding
Hepatitis B or C
Drug or Alcohol Addiction
Any other serious illness or injury:
Please list all current medications you are taking, and/or you have used in the past 6 months including: Birth Control, Aspirin or ibuprofen, Weight loss medication, Coumadin, or any blood thinning medication, prescription eye drops, steroids, or antibiotics:
Check all Skin Conditions
Melanoma or Skin Cancer
Check all topical medications
List all surgeries you have had (including plastic surgery):
Check Box for YES response:
Have you ever seen a Dermatologist for your skin Reason?
Are you pregnant or lactating? How many months
Have you ever taken Accutane? When?
Do you have a history of Herpes Simplex (cold sores)? Last Outbreak?
Do you have a history of developing Keloids (raised scars)
Do you have irregular periods? Explain:
Do you smoke cigarettes or use tobacco products? How often?
Do you use recreational drugs? How often?
Do you drink alcohol? How often?
Have you ever been diagnosed with cancer? What kind and when?
What vitamins or supplements are you currently taking?
List all current skin care products
I am aware of the 48 hour cancellation policy. There will be a $50 charge for any treatment or consultation not cancelled at least 48 hours in advance. A full consultation fee or partial procedure fee of $125 will be charged for cancellation less than 24 hours.
Photographs are part of a detailed skin analysis. I consent to the taking of clinical photography and its use for controlled purposes in publications, presentations and marketing promotions. I fully understand that my identity will be protected.