DBA JENNIFER M. LEE FNP, LLC

1314 S. King Street, #604

Honolulu, HI 96814

808-546-9544

Full Name

Date of birth

Address

Street Address

City

State

Country

Postal code

Cell Phone

Phone *

Email *

Preferred Method of Contact

Cell Phone

Home Phone

Email

Would you like to be on our e-mail list to receive product/service specials?

Yes

No

How did you hear about JenMedical Aesthetics?

Emergency Contact Name:

Relationship:

Emergency contact phone number:

Other concerns:

Are you currently having any skin treatments?

Yes

No

If yes, what type?

HEALTH HISTORY

What type of work do you do?

What is your genetic background? Example, Asia, Hispanic, Indian, French, etc.

If yes, please list reason for visit:

Are you currently taking medications or supplements?

Yes

No

If yes, please list:

How is your general health? (check one)

Excellent

Good

Fair

Poor

FEMALE ONLY – Are you currently:

Nursing

Pregnant

Planning to become pregnant

# of Pregnancies

Any additional health problems or medical conditions? Please list:

ALLERGIES: Please list any known allergies :

HOMECARE:

SUN PROTECTION

Do you ever use sunscreen?

Yes

No

How Often?

What level of protection (SPF number?)

Most recent prolonged sun exposure?

PHOTOGRAPHIC CONSENT

I give consent to be photographed for the purpose of medical records.

Yes

No

I give the consent to be anonymously photographed for marketing and/or publication.

Yes

No

Patient Signature

Clear

Date