CASCADE FACES
Aesthetics and Facial Plastic Surgery
Patient Name:
Patient Account Number:
PATIENT INFORMATION
Last name:
First name:
Date of Birth:
Middle initial:
Gender: Male Female SSN:
Phone (H):
Marital Status: M S W D
Phone (W):
May we leave a message? Yes
ext.
Phone (C):
No
Address:
City/State:
Zip:
Email:
May we email you product/service special offers or seminar information at this address:
Yes
No
REFERRED BY: (please specify in the space provided)
Self
Relative
Bulletin
Another patient
Magazine
Spa/Salon
Yellow Pages
Employee
Friend
Other
Seminar
Physician
Website
Internet
REASON FOR TODAY’S VISIT:
AUTHORIZATION FOR DISCLOSURE/RELEASE OF INFORMATION
I authorize Cascade Faces Aesthetics and Facial Plastic Surgery Center to disclose complete information concerning medical finding
and treatment of the undersigned, from the initial office visit until date of the conclusion of such treatment, to those individuals who, in
Cascade Faces Aesthetics and Facial Plastic Surgery Center determination, are required to receive such information for the purpose of
medical treatment, medical quality assurance, peer review, and if applicable to process the insurance claim for services rendered at
Cascade Faces Aesthetics and Facial Plastic Surgery Center.
Signature:
Date:
431 NE Revere Ave Suite 110 Bend, OR 97701
p. (541)312-3223 f. (541)330-2499
www.CascadeFaces.com
CASCADE FACES
Aesthetics and Facial Plastic Surgery
Patient Name:
Patient Account Number:
PATIENT HISTORY
First Name:
Last Name:
Date of Birth:
Height:
Age:
Date:
Weight:
Current Weight Loss?
Are you currently pregnant or lactating?
Have you ever been pregnant?
During pregnancy, did you experience hyper pigmentation?
Areas:
Comments:
Do you currently have regular periods?
Are you currently going through menopause?
Do you wear contact lenses?
Do you use tanning booths?
Do you currently have a sunburn or windburn?
Area:
Do you currently have waxing / electrolysis treatments?
Area:
Are you currently using Biore’ or other acne strips?
Area:
Are you currently using Retin-A, Renova or Differin?
Strength:
How frequently?
For how long?
Area:
Are you currently using Acutane?
For how long?
Are you currently having microdermabrasion?
For how long?
Do you have regular filler (Restylane, Collagen, etc.) injections?
Do you have regular Botox injections?
Last injection?
Last injection?
What type of work do you do?
Do you participate in vigorous aerobic activity and how often?
Have you ever had a peel?
Type of peel?
Date of last peel?
Describe your reaction?
Have you recently had facial surgery?
Type and date:
Have you ever had laser resurfacing?
Type and date:
431 NE Revere Ave Suite 110 Bend, OR 97701
p. (541)312-3223 f. (541)330-2499
www.CascadeFaces.com
CASCADE FACES
Aesthetics and Facial Plastic Surgery
Patient Name:
Patient Account Number:
Do you smoke?
Packs per week and for how long:
Do you develop cold sores or fever blisters?
Last breakout:
Are you allergic or sensitive to any of the following? Please check all that apply
Milk
Apples
Perfumes
Any other allergies?
Citrus
Grapes
Latex
Aloe Vera
Aspirin
Hydroquinone
Are you sensitive to alcohol based products?
Are you taking any medications at this time, over-the-counter or RX?
Describe your skin from the following choices, please check all that apply.
Thick
Thin
Firm
Normal
Combination
Oily
Comedones
Milia
Breakouts
Scarred
Small Pores
Florid
Eczema
Freckled
Uneven/Blotchy
Mature
Patchy Dryness
Sallow
Perfume-stained
Hypo-Pigmentation
Psoriasis
Dehydrated
Broken Capillaries
Saggy
Dry
Acne Prone
Cystic
Large Pores
Rosacea
Sun-damaged
Wrinkled
Melasma
Hyper-Pigmentation
Asphyxiated
Which of the following do you consider your skin to be? Please check one of the following
Sensitive
Resilient
Not Sure
Eye color:
Blue
Light Brown
Natural hair color:
Blonde
Medium Brown
Gray/Silver
Skin tone:
Pale/ white
Reddish
Medium Olive
Medium Brown
Black
Green
Medium Brown
Gray
Dark Brown
Red
Dark Brown
Light Brown
Black
Light
Freckled
Dark Olive
Dark Brown
Sallow
Medium
Light Olive
Light Brown
Soft Black
431 NE Revere Ave Suite 110 Bend, OR 97701
p. (541)312-3223 f. (541)330-2499
www.CascadeFaces.com
CASCADE FACES
Aesthetics and Facial Plastic Surgery
Patient Name:
Patient Account Number:
What is your hereditary make-up?
Are you using glycolic / AHA home care products?
Please list:
How does your skin react to them?
Have you ever used any products that cause a bad reaction?
What is your daily home care regimen?
What are the cosmetic improvements you would like to see in your skin?
Any comments:
Patient Signature:
Aesthetician Signature:
431 NE Revere Ave Suite 110 Bend, OR 97701
p. (541)312-3223 f. (541)330-2499
www.CascadeFaces.com