Please describe any concerns you would like to discuss at your appointment.*
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Medications/Medical Treatment
Please list all Medication Allergies and Reactions.
Do you take Aspirin or any blood thinners (Aleve/Ibuprofen/Fish oil) daily?*
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Do you take Aspirin or any blood thinners (Aleve/Ibuprofen/Fish oil) daily?*
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If you answered yes above, please describe
Do you use Accutane or have you used Accutane within the last year?*
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Do you use Accutane or have you used Accutane within the last year?*
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Do you currently use a Retin-A or Tretinoin?*
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Do you currently use a Retin-A or Tretinoin?*
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Please list all medications you are currently taking including all herbal supplements.*
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Are you currently under the care of a physician for any condition?*
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Are you currently under the care of a physician for any condition?*
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If you answered yes above, please describe
Do you have a history of any of the below conditions?
Skin cancer
Skin cancer
Yes
No
Heart Disease
Heart Disease
Yes
No
Heart Arrhythmia
Heart Arrhythmia
Yes
No
Lung Disease
Lung Disease
Yes
No
Thyroid Disease
Thyroid Disease
Yes
No
Shortness of breath with stairs
Shortness of breath with stairs
Yes
No
Chest Pain
Chest Pain
Yes
No
Sleep Apnea
Sleep Apnea
Yes
No
Diabetes
Diabetes
Yes
No
Difficulty Healing or Scarring
Difficulty Healing or Scarring
Yes
No
Hepatitis A/B/C
Hepatitis A/B/C
Yes
No
HIV
HIV
Yes
No
Seizure/Stroke
Seizure/Stroke
Yes
No
Pollen Allergies
Pollen Allergies
Yes
No
Dry Eye
Dry Eye
Yes
No
Lasik Eye Surgery
Lasik Eye Surgery
Yes
No
Depression/Other Psychological Disorders
Depression/Other Psychological Disorders
Yes
No
If you answered yes to any of those conditions, please describe
Please list all previous surgeries with approximate date
Have you had any complications from anesthesia?*
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Have you had any complications from anesthesia?*
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If you answered yes above, please describe
Do you smoke, vape, or use any form of nicotine?*
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Do you smoke, vape, or use any form of nicotine?*
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If you answered yes above, please describe
Do you drink alcohol?*
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Do you drink alcohol?*
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If you answered yes above, how much?
Do you use illegal substances?*
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Do you use illegal substances?*
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Are you currently pregnant or breastfeeding?*
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Are you currently pregnant or breastfeeding?*
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Have you had any non-surgical treatments (Botox, Fillers, Lasers, Peels)?*
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Have you had any non-surgical treatments (Botox, Fillers, Lasers, Peels)?*
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If you answered yes above, please describe
Describe your history of sun exposure.
Are you interested in any non-surgical treatments?
Do you currently use a skincare regimen?*
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Do you currently use a skincare regimen?*
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If you answered yes above, please describe
Would you like to be added to our email list to receive a monthly special?*
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Would you like to be added to our email list to receive a monthly special?*
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