Patient Registration

First Name *

Last Name *

Date of birth *

Address

Street Address

City

State

Country

Postal Code

Home Phone *

Cell Phone

Work Phone

Email *

Occupation

Emergency Contact

Emergency Contact Phone Number

How did you hear about us?

Referred by:

Skin Care

Which of the following best describes your skin type?

Very Oily Skin

Acne

Sensitive

Normal

Large Pores

Dry Skin

Combination

What is your daily skin care regimen?

How would you rate the overall quality of your skin?

Poor

Fair

Good

Very Good

Are you currently using any topical medication (like Retin-A®) or exfoliating acids like salicylic or glycolic?

Yes

If yes, explain

Are you currently using or have you used Accutane® in the past 12 months?

Yes

Do you wear contact lenses?

Yes

Are you wearing them right now?

Yes

What improvements would you like to see to your skin?

Sun History and Lifestyle

How often do you work outdoors?

Frequently

Occasionally

Rarely

How often do you use sunscreen?

Frequently

Occasionally

Rarely

How often do you tan or wear self-tanner?

Frequently

Occasionally

Rarely

Medical History and Allergies

Please list all current medications, prescriptions, and homeopathic supplements:

Please list all allergies:

Do you have or have you ever had any of the following?

Cancer

Diabetes

Heart Disease

Heart Problems

HIV or Other Immune Deficiency Disorders

Epilepsy

Liver Disease

Hormone Imbalance

Herpes/Cold Sores

Hepatitis

Skin Disorder

Previous Procedures

Which of the following have you had in the last three months?

BOTOX®

Xeomin®

Radiesse®

Voluma®

Chemical Peels

Permanent Makeup

Skin Rejuvenation

Facial Plastic/Reconstructive Surgery

Dysport®

Fillers/JUVEDERM®

Restylane®

Microdermabrasion

Laser Hair Removal

Skin Resurfacing

Skin Tightening

Other

Other Procedure(s)

Are you pregnant or breastfeeding?

Yes

Are you interested in learning more about any of the following?

Microdermabrasion

Chemical Peels

PRP

Plastic Surgery

Fillers

Laser IPL

Specials/Packages

Other

Other interest:

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(304) 205-6123

(304) 760-4000

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