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Medical Intake Form

EMERGENCY CONTACT:

Check all Medical Conditions:

Bleeding tendency
Blood transfusion
Irregular heartbeat
High Blood Pressure
Ulcers or Bleeding
Rheumatoid Arthritis
Lupus
Diabetes
Stroke
Heart Disease
Heart Attack
Chest pain
Scleroderma
Depression
Dry eyes
Bronchitis
Lung disease
TB
Asthma
Emphysema
Epilepsy
Hypomelanism (albinism)
Glaucoma
Porphyria
Heart Burn
HIV
Hepatitis B or C
Drug or Alcohol Addiction
Mental Illness

Eczema
Psoriasis
Melanoma or Skin Cancer
Acne
Rosacea
Vitiligo
Retina A
Salicylic Acid
Glycolic Acid
Benzoyl Perozide
Antibiotic

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?

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.