* = Required Information
Date of Birth
How did you hear about us?
In case of emergency: Name of friend or relative we can contact
Why did you come to see us today?
Are you pregnant or nursing at this time?
When was last menstrual period?
Other Areas of Concern: (Please ✔ all that apply)
Fine Lines & Wrinkles
Smile Lines or Deep Wrinkles
Sun Damage or Age Spots
Unwanted or Excess Hair
Dull or Lifeless Skin
Please answer the following question to the best of your knowledge. This information will be used in order to provide you with a better quality of care.
Please indicate any previous surgeries or past hospitalizations:
Operations and Reason
Past Illnesses: Please check (✔)
Has any member of your family had any of the above?
Which family members?
Skin Type: (When exposed to the sun without protection for about an hour) Please check (✔)
Always burns, never tans
Always Burns, sometimes tans
Sometimes burns or tans
Hispanic, Asian, Mediterranean
Do you develop cold sores or fever blisters?
Are you pregnant?
Do you develop keloid scarring?
Have you ever taken Accutane?
If you smoke, how much?
If you drink, how much?
Bleeding disorder or bruises easily?
Endocrine or Hormone issues?
Any dermatological conditions?
I understand that payment is due in full at the end of my treatment unless other arrangements were made prior to my appointment.
NEW PATIENT CONSULT DONE BY:
Sarah Edwards, PA-C
Mubina Siddiqui, NP
Amanda Paranda, PA-C