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Aesthetic Clinic and Medical Spa DC
2025056996
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About Us
SKIN PROCEDURES
BOTOX CLINIC WASHINGTON DC
CUSTOM CHEMICAL PEELS DC
Superficial Chemical Peels
Medium Chemical Peels
Deep Chemical Peels
DERMAL FILLERS
DIAMOND GLOW “DERMAL INFUSION”
DERMAPLANING
LASER HAIR REMOVAL WASHINGTON DC
Types of Laser Hair Removal
LASER SKIN RESURFACING
LED PHOTOTHERAPY
BLUE LED THERAPY
RED LED THERAPY
SKIN MICRONEEDLING Washington DC
TATTOO REMOVAL
TIXEL NON-INVASIVE SKIN REJUVENATION
Medical Weight Loss Clinic DC
BODY SCULPTING TREATMENT Washington, DC
Appointments
Appointment for Acne Treatment Program
Appointment for Chemical Peel
Appointment for Dermal Filler Injection
Appointment For Eye Rejuvenation
Appointment for Hair Restoration
Book an appointment for Botox
Book an Appointment for Skin Tightening or Body Sculpting
Book an Appointment For Tattoo Removal
Book Appointment for Fat Injection
Book Appointment For RF-IPL Photofacial
Book Dermal Infusion
Book Dermaplaning appointment
Book Intimate Area Lightening Program
Book Laser Body Sculpting
Book Laser Hair Removal
Book Laser Resurfacing
Book Skin Microneedling
Book Tixel Skin Rejuvenation
Shop Skincare
Acne Treatment Products
Anti-Aging Skincare Products
Skin Treatment Serums
Moisturizers
Face Cleansers
Body Products
Gift Cards
Sunscreen
AnewSkin Programs
ACNE PROGRAM
GLOWING SKIN RENEWAL.
ANTI-AGING PROGRAM
Patient Resources
New Patient Forms
Cancellation Policy
Enter Our Raffle
Specials
Skincare Blog
Contact Us
New Patient Forms
Medical Intake Form
Name*:
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DOB*:
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Today's Date:
Address*:
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City/St/Zip:
Height:
Weight:
Allergies:
Cell Phone*:
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Home Phone:
E-Mail*:
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Occupation:
How did you hear about us?*:
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EMERGENCY CONTACT:
Name*:
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Relationship*:
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Phone*:
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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
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
Eczema
Psoriasis
Melanoma or Skin Cancer
Acne
Rosacea
Vitiligo
Check all topical medications
Retina A
Salicylic Acid
Glycolic Acid
Benzoyl Perozide
Antibiotic
List all surgeries you have had (including plastic surgery):
Date
Surgery
Date
Surgery
Date
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.
Signature*
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Date*
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