Client Information
Date:_________________
Name:________________________________________________________
Address:______________________________________________________
City, State, Zip:________________________________________________
Home:______________Work:_______________Cell:__________________
Birth Date:___/___/____ Age:______Gender:(circle one) Male
Female
E-mail:_______________________________________________________
May we send you our newsletter and promotions via email? ___NO ___YES
Occupation:__________________________Employer:________________________
Referred By:_________________________________
Home:_________ Cell____________ Work______________
Reason for today’s visit_________________________________________________
Listed below are our skin care services, please check all that you are
interested in:
________Botox
________Exfoliation Treatments
________Chemical Peels
________Laser Hair Removal
________IPL (Laser Rejuvenation)
________Dermal Fillers
________Sciton Micro Laser Peel
________Pro Fractional Laser Treatment
________Latisse
________Nutritional Counseling
_______Body Massages
_______Facials
_______PCA Skin Care
_______Obagi Skin Care
_______ Jane Iredale Make up
_______ Far Infrared Sauna
_______Physician Nutrients Supplements
_______5 x 5 Weight Loss program
_______Body waxing
_______Body Scrub Treatments
Signature:_________________________________Date:________________
**IF YOU HAVE ALLERGIES TO LATEX, MEDICATIONS, OR LIDOCANE
PLEASE NOTIFY US IMMEDIATLEY!**
Personal Health
Name:_____________________________Date:_______________
Medical History
Skin Type- when exposed to the sun without protection for about 1 hour you:
_____Type 1—Always burn, never tan, extremely sun sensitive, Northern European , light eyes,
light eyelashes, light white skin.
_____Type 2---Always burns easily, sometimes peels, sometimes tans, predominantly Northern
European, light white skin.
_____Type 3---Usually burns, tans gradually to light brown, ½ Northern European, ½ other
ethnic group, medium white skin…
_____Type 4---Rarely burns, always tans to moderate brown, Southern Italian, American
Indian, Portuguese, Greek, light skinned Hispanics, light skinned Northern African Middle
Eastern (Arab, Iranian, Iraqi) light brown.
_____Type 5---Very Rarely (if ever) burns, tans and gets darker, dark skinned North AfricanMiddle Eastern, dark skinned Hispanics, Indian, Pakistani, Asians (Japanese, Chinese, Koreans,
Etc) medium brown and highly pigmented.
_____Type 6---Never burns, African American, African, dark Asian, mixed Caucasian/Black,
dark brown skin.
1. Answer the following questions:
How much?
Do you get sun exposure?
Y N _______________
Have you ever used tanning beds?
Y N _______________
Do you smoke?
Y N _______________
Do you have keloid formation or scars?
Y N _______________
Do you have cancer of any kind?
Y N _______________
Do you have skin disorders?
Y N _______________
Do you take allergy medications
Y N _______________
Do you wear contact lenses?
Y N _______________
Have you ever had cold sores/fever blister?
Y N _______________
Do you have metal implants or a pacemaker?
Y N _______________
Do you currently get Botox?
Y N _______________
Do you currently get Cosmetic Fillers?
Y N _______________
Do you have permanent make-up?
Y N _______________
Are you trying to become pregnant? Y N Are you pregnant or lactating? Y N
Are you going through menopause? Y N Are you post menopause?
Y N
2. List all substances you are allergic to (meds, foods, cosmetics, latex)
___________________________________________________________
3. List all medical conditions and/or major surgeries you have had in past 5 years
_____________________________________________________________________
4. List any medications, herbal supplements & vitamins you are currently taking
(St.Johns Wart, Doxcycline, Minocycline, Tetracycline)
_____________________________________________________________________
Skin Care History
Name:___________________________Age:_______Date:______________
Skin Health
1. Have you ever been under the care of a physician (dermatologist) for your
skin? Y N If yes please explain __________________________________
_____________________________________________________________
2. List the skin care product you are currently using:___________________
_____________________________________________________________
3. Note any skin concerns you would like to address:___________________
_____________________________________________________________
Ex: Dry, Oily, Acne, Breakouts, Sun Damage, Brown Spots, Aging Skin, Fine Lines, Rosacea, Eczema etc.
4. Note any of the following that you have ever done.
Date
Frequency
Type
Facial
Y N_ _________________________________________
Electrolysis/Waxing Y N__________________________________________
Chemical Peel
Microdermabrasion
Laser Resurfacing
IPL treatment
Laser hair removal
Y N__________________________________________________
Y
Y
Y
Y
N__________________________________________
N__________________________________________
N _________________________________________
N _________________________________________
5. Note any of the following TOPICAL applications you have used:
Antibiotics
Steroid Creams
Hydrocortisone
Benzoyl Peroxide
Retin A
Retinol
Renova
Vitamin C
Glycolic Acid
Lactic Acid
Alpha Hydroxy Acids
Hydroquinone
6. Are you taking any medications that will make you sensitive to sunlight?
Yes / No If so what products?
7. Answer the following questions?
Have you used Accutane?
Y N Have you recently done aggressive exfoliation? Y N
Have you recently had sunburn? Y N Do you flush or “appear reddened” easily? Y N
Do you use sunscreen regularly? Y N Do you have issues with healing or scarring? Y N
Have you ever had skin cancer? Y N If so, what type and where on the body?________
Signature:________________________________Date:_________________
Patient Photography Consent
For your consideration, I undersigned, herby give SKIN WELLNESS MD,
permission for use of the photographs taken of me.
(1) Only for the use of Pre and Post procedure reasons.
I am of legal age. I have read the above fully and understand its contents.
Patient Name:______________________________Date:____________
Witness Name:_____________________________Date:____________
Cancellation Policy
SKIN WELLNESS MD will charge a $25 cancellation fee for all cancelled
appointments with less than 24 hours notice.
New patients are subject to a $50 cancellation fee on a missed or cancelled
appointment with less than 24 hours notice.
Please be respectful of our technician’s time and let us know in advance if you
need to change an appointment, we are a busy office and other patients would be
willing to take your appointment time.
If you need to cancel or change an appointment please notify the office 24 hours
in advance or you will be subject to the cancellation fees.
Patient Name:_________________________Date:________________
Witness Name:_________________________Date:________________