Today’s Date _________________
WELCOME to Elizabeth Marion Clinical Skin Care!
Please take a moment to fill out this information so we
can best assist you with your skincare and laser needs!
Name ___________________________________________________________
Address__________________________________________________________
City_____________________ State___________ Zip _____________________
Home phone___________________ Cell phone__________________________
Email____________________________________________________________ (please print clearly)
Date of birth ____________________________
Referred by _____________________________
Updated 1/2014
GENERAL HEALTH RECORD
1. Have you ever been diagnosed with any of the following skin
disorders?
Acne
Seborrhea
Psoriasis
Skin Cancers
Mycosis (fungal infection)
Eczema
Rosacea
Contact Dermatitis
2. Do you suffer from any allergies? **IMPORTANT
(Cosmetic ingredients, food, iodine, medications, hay fever, latex)
 NO  YES (please specify) ______________________
Citrus Allergies?
3. Are you currently undergoing chemotherapy or radiation
therapy?
NO
YES (please specify) _____________________
4. Are you currently taking any medications, herbs, vitamins?
Internal:_______________________________________________
________________________________________________________
External:______________________________________________
*Retinol?________________________________________________
6. Do you have any body implants?_______________________
7. Have you ever been diagnosed with any of the following?
Anxiety
Depression
Migraines
Asthma
Sinus Problems
High Blood Pressure
8. Do any of the following apply to you?
Smoke
Exercise
If yes, last date used?______________________________
Wear Contact Lenses
9. When exposed to the sun, do you? (Very Important for any
Laser Treatments)
Burn Easily Tan Easily Never Burn Never Tan
12. How many glasses of water do you consume daily?
1-2
3-5
6-8+
13. For Women Only...
Regular Menstruation
Hormonal Problems
IUD (copper or plastic)
5. Have you ever been prescribed Accutane®?
Cancer
Hemophilia
Diabetes
Hepatitis
Thyroid
Herpes
Epilepsy
HIV
Heart Problems Other ____________
Low Blood Pressure
Pregnant
Menopause
Lactating
Birth Control Pill
FACIAL ANALYSIS
*For an effective treatment, please be as accurate as possible
Skin Type
Eye Area
Crows Feet/Wrinkles Puffiness Lack of Elasticity
Shadows
Normal Dry Sensitive Combination Oily
Sensitive/Breakout Very Sensitive/Rosacea Acne Mature
15. What are your present skincare concerns?
Please check all that apply
Acne Lesions (cysts) Papules(inflamed) Blackheads
Acne Scars
Pustules(inflamed) Whiteheads
Dilated Capillaries Ingrown Hairs Enlarged Pores
Hyper pigmentation (brown spots from sun, scars, hormonal)
16. How often do you receive a facial?
Regularly
---OVER---
Seldom
Never
Dark
17. Have you recently received any of the following
spa services?
Microdermabrasion
Enzyme Peels
Acid Peels
Waxing Services
Date ______________
Date ______________
Date ______________
Date ______________
18. Have you received any of the following medical or
surgical procedures?
Rhytidectomy (Face lift)
Rhinoplasty (Nose)
Blepharoplasty (Eye lift)
Laser Resurfacing
Dermabrasion
Medical Acid Peels
Collagen Injections
Dysport
Botox® Injections
Date ___________
Date ___________
Date ___________
Date ___________
Date ___________
Date ___________
Date ___________
Date ___________
Date ___________
19. Do you use any of the following?
Eye Make-Up Remover
Cleanser
Toner
Moisturizer
Exfoliate
Mask
Make-up
Sunscreen
Brand ___________________
Brand ___________________
Brand ___________________
Brand ___________________
Brand ___________________
Brand ___________________
Brand ___________________
Brand ___________________
20. If you could improve one thing about your skin, what would
it be?
_________________________________________________________
_________________________________________________________
We are delighted that you are here! We will discuss and review treatment options during your
complimentary consultation and possible treatment(s) today. Please sign the CLIENT CONSENT FORM as
indicated below.
I hereby consent to and authorize Midtown Medi-Spa to perform the following procedure(s): chemical peels,
dermaplaning, facials, waxing, make-up application, extractions, esthetic-services, lash or brow tinting,
vascutouch, laser hair removal and IPL Intense Pulse Light /Yag treatments. Tattoo and permanent makeup or
other procedures recommended.
I understand every procedure or treatment has risks and benefits. I understand that being in the sun and heat
can diminish my results. Although it is impossible to list every potential risk and complication, I have been
informed of possible benefits, risks and complications. There are NO GUARANTEED RESULTS and results are
dependent upon age, skin condition, and lifestyle and that there is the possibility they you may require further
treatments of the treated areas to obtain the expected results at an additional cost to you.
I will update Elizabeth Paner, LE of any medical changes or topical and /or internal medications that you are
taking. This is important because certain medications affect peel and laser treatments.
I cannot stress enough that any type of tanning or sun exposure does not mix with laser treatments. Please
do not use any sunless tanning products…it affects your treatments. Please understand the post treatment
instructions. I will call Midtown Medi-Spa immediately if I have any concerns or questions about my
treatment(s).I fully read and understand this agreement and have been accurate as possible. I understand
that facials, peels, laser and laser hair removal is not an exact science and I will not hold Midtown Medi-Spa,
Elizabeth Paner or Dr. Lowne liable for anything performed past or present. Please DO NOT SIGN IF YOU DO
NOT UNDERSTAND.
Polices please initial:
_______Midtown Medi-Spa requires a 24 hour cancellation
*****please note that full amount will be charged or a treatment will be deducted from your
packaged that was purchased.
______No children are allowed inside the treatment under the age of 12 (sorry I do love kids)
_______NO REFUNDS ON ANY TREATMENT(s) AND OR PRODUCTS
Name (signature)______________________________________ Date ____________________
Thank you,
Medical Director: Dr. Yvonne Lowne and Elizabeth Paner, Owner and Licensed Aesthetician