Profile Sheet
Today’s Date: _______
Name: _______________________________________________
DOB: ________
Address: ______________________________________________________________
Phone: _____________
Cell: _______________
Age: ______
Sex: ____
State: _____
Zip: _______
Email: _______________________
Emergency Contact: ______________________
Phone: __________________
Skin Type:
Medium _____
Fair _____
Tan _____
Who do we thank for referring you? ______________________________
Do you have any questions regarding this procedure? ____________________________________________________
__________________________________________________________________________________________________________________
Allergies: (medications, ointments, creams, milk, fruits, aloe vera, citrus, etc.) __________________________
__________________________________________________________________________________________________________________
What allergic reactions have you experienced in the past? ________________________________________________
__________________________________________________________________________________________________________________
Please list any medications and skin care products that you are currently taking and why?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Have you ever experienced any reactions to anesthesia? If ‘yes’, please explain ________________________
__________________________________________________________________________________________________________________
Have you ever received radiation treatment? If ‘yes’, please explain _____________________________________
__________________________________________________________________________________________________________________
Do you smoke? _______
How long? _______
Do you drink? ______
# of drinks per week? _________
Drug use? __________
Name _________________________________
DOB ________________
Have you ever been treated for:
Yes
No
Yes
No
High blood pressure
____
____
Liver Disease
____
____
Heart problems or stroke
____
____
Cancer
____
____
Angina
____
____
Varicose Veins
____
____
Shortness of breath
____
____
Anemia
____
____
Pulmonary Embolism
____
____
Asthma/Bronchitis
____
____
Migraine Headaches
____
____
Fever Blisters
____
____
Hemophilia
____
____
Blood Transfusion
____
____
Stomach problems
____
____
Yellow Jaundice
____
____
Arthritis
____
____
Hepatitis
____
____
Bell’s Palsy
____
____
Facial Nerve Damage ____
____
Epilepsy
____
____
Glaucoma
____
____
HIV
____
____
Glasses/Contacts
____
____
Diabetes
____
____
Mitral Valve Prolapse ____
____
Depression
____
____
Mental Conditions
____
____
__________________________________________________________________________________________________________________
Have you ever taken Accutane? ____
When? ____
Dosage? ____
Months? ____
Have you used Tretinoin? ____ %? ____
Do you have herpes simplex? ____
Have you used Valacyclovir? ____ Zovirax? ____ Valtrex? ____
Birth Control pills? ____ Currently Pregnant? ____ Breast Feeding? ____ Attempting Pregnancy? ____
Skin Tans? ____ Skin Burns? ____
Pre-cancerous lesions? ____ Lesion removal? ____ When? ____
Mole removal? ____ When? ____
Hair removal? ____ Wax? ____ Electrolysis? ____ Laser? ____
Permanent make-up? _____
Other: __________________________________________________
Page 2 of 4
Name __________________________
DOB ______________
Previous Resurfacing Procedures (Please Give Dates)
CO2 ____ Erbium ____ Dermabrasion ____
Peels: Phenol ____ TCA ____ Glycolic ____ Salicylic ____
Home Skin Products
Cleanser __________________
Times/day _____
Toner/Astringent _______________________
Moisturizer ___________________ Eye cream ____________________
Exfoliator ________________________________
Sunscreen use _________________ Make-up? __________________
Other: ____________________________________
Areas of Concern
Lines/Wrinkles Skin Texture Skin Elasticity Even Color/Tone Psoriasis/Eczema
Acne Scars/Acne Skin Disorder ______________________ Other Concerns __________________________________
Patient Skin Analysis (circle all that apply)
Moisture: Oily Combination
Dry
Normal
Texture: Thick Thin Normal
Wrinkles: Fine Deep
Acne: Y/N
Keloids
Type:__________
Scarring
Enlarged Pores
Acne Scars: Y/N
Pigmentation
Elastosis
Other Scars: _____________________________
Telangiectasia
Keratosis
Skin Color Analysis
Caucasian:
light
medium
dark
very dark
Asian:
light
medium
dark
very dark
Hispanic:
light
medium
dark
very dark
Indian:
light
medium
dark
very dark
African American:
light
medium
dark
very dark
Page 3 of 4
Milia
Comedones
ACKNOWLEDGEMENT
I ACKNOWLEDGE AND UNDERSTAND THAT FACE HAVEN, LLC IS RELYING UPON THE ACCURACY
OF ALL OF THE ABOVE INFORMATION AND REPRESENTATIONS IN DECIDING IF AND HOW IT
MAY PROCEED SAFELY WITH MY TREATMENT. BY MY SIGNATURE BELOW, I CERTIFY THAT ALL
OF THE ABOVE INFORMATION AND REPRESENTATIONS ARE COMPLETELY TRUE AND ACCURATE
AND WERE PROVIDED BY THE UNDERSIGNED. I ALSO ACKNOWLEDGE AND AGREE THAT FACE
HAVEN, LLC SHALL HAVE NO RESPONSIBILITY OR LIABILITY FOR ANY REACTIONS, INJURIES
AND/OR OTHER OR RELATED DAMAGES OR CONDITIONS CAUSED BY OR ARISING FROM, IN ANY
WAY, ANY INCORRECT INFORMATION PROVIDED ABOVE AND/OR FACE HAVEN, LLC’S RELIANCE
THEREON, AND I WAIVE ANY CLAIMS AGAINST FACE HAVEN, LLC ARISING IN ANY WAY FROM
THE SAME.
____________________________________________
Signature of Patient or Legal Guardian
________________________________
Print name/Relationship
Page 4 of 4
________________
Date