Patient Information & Medical History
Thank you for choosing The Skin Clinic Medi Spa. Your well being and safety are our concern as we deliver your results driven treatments. Please assist us by completing the following information:
Date ________________________ Reason for visit? _________________________________
Title _________ First ______________________ Last ____________________ M.l. ________
Street Address _____________________________________________ Apt# ______________
City ______________________________________ State __________ Zip _______________
Home Phone ___________________________ Cell Phone ____________________________
Work Phone __________________________ Preferred Contact Number _________________
Email Address ________________________________________________________________
Date of Birth __________________________ Anniversary (optional) _____________________
Occupation (optional) __________________________________________________________
How did you hear about us? _____________________________________________________
Emergency Contact Name & Number ______________________________________________
Are you currently under a physician’s care? _________________________________________
What if any medications are you taking? ____________________________________________
Do you use Retin-A? ______ Have you used Accutane _____ if yes, when? _______________
Please check if you are affected by or have any of the following:
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Allergies
Asthma
Back Problems
Bone or Nerve Injury
Bleeding Problems
Cancer
Cardiac Arrest
Cellulite
Claustrophobia
Diabetes
Eczema
Epilepsy
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Fever Blisters
Herpes/Cold Sores
Heart Condition
Hepatitis
High/Low Blood Pressure
HIV/AIDS
Immune Disorders
Keloids/Abnormal Scarring
Lupus
Pacemaker
Photoallergic
Poor Wound Healing
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Pigmentation Problems
Prosthetic Heart Valve
Psychological Problems
Radiation Treatments
Sinus Problems
Skin Diseases/Skin Cancer
Skin Rashes
Stretch Marks
Suspicious Growths
Thyroid Problems
Varicose Veins
Metal Bone, Pins or Plates
75 PROSPECT STREET, STE. 115, HUNTINGTON, N.Y. 11743
WWW.THESKINCLINICONLINE.COM | (631) 456-2075

Do you have any allergies? _______________________________________________________
(Please list, ex: Shell Fish, Iodine, Hay Fever, etc.)
Are you pregnant? ____________ If yes, no. of weeks/months? __________________________
Do you smoke? ______________ Do you wear contact lenses? __________________________
Are you presently under a physician’s care for any current skin condition? __________________
Name and number of your physician? _______________________________________________
Have you ever experienced any form of acne? _____________ If yes, what age? ____________
Do you ever experience any acne breakouts? _________________________________________
Please indicate any concerns you have about your skin? ________________________________
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Would you like to learn about improving your skin with Peak Performance Skin Technologies?
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Do you go in the sun of tanning booth? ___________________ Do you use SPF _____________
Have you ever had or are you considering plastic surgery? ______________________________
Have you ever had Botox and/or facial fillers? ________________________________________
If you answered yes to any of the above, please explain _________________________________
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Is there any additional medical information not listed above that pertains to your current, past or future health? __________________________________________________________________
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I understand that the service offered at The Skin Clinic Medi Spa are not a substitute for medical care, and any information provided y the staff is not diagnostically prescriptive, which is only intended to provide better service and is completely confidential.
I fully understand and agree to the above statement.
Patients Signature ___________________________________________ Date _______________
75 PROSPECT STREET, STE. 115, HUNTINGTON, N.Y. 11743
WWW.THESKINCLINICONLINE.COM | (631) 456-2075