File - CMG Aesthetics

Name: _______________________________________________________________________
Address: _________________________________________________DOB: ________________
Telephone: ____________________ OK to leave message? ___________________________
If you would like to be notify about upcoming events and promotions, please provide your e-mail
address: _______________________________________________________________________
What brings you to the office today? _________________________________________________
What are your areas of concern? (Please check all that apply)
___ Frown lines between the brows
___ Fine lines and wrinkles
___ Large pores
___ Lines around nose and mouth
___ Rough skin texture
___ Red areas
___ Brown spots
Other: ___________
___ Sun damage
___ Acne
Are you interested in learning more about the following? (Please check all that apply)
___ Chemical Peels
___ Skin rejuvenation
___ Injectable Fillers
___ Skin care products
Other: _________
Current medications (including any supplement use): ______________________________________
(Please include all the medications such as vitamins, aspirin, herbs etc.)
Allergies: ____________________________________________________________________________
Are you breastfeeding? _________________________________________________________________
Are you pregnant? ____________________________________________________________________
Do you smoke? _______________________________________________________________________
Do you have any neuromuscular disorders (i.e. Parkinson’s)? _________________________________
What is your skin care routine? _________________________________________________________
Have you had any facial surgery, fillers, Botox, laser treatments recently? If yes, what and when?
How would you describe your skin being exposed to sun?
___ always burns, never tans
___ burns minimally, tans easily
___ burns easily, sometimes tans
___ rarely burns, tans dark easily
___ sometimes burns, always tans
___ never burns, always tan dark
How did you hear about us?
___ Friend / family member
___ Internet / Website
___ Physician
___ Seminar
___ Ad or article
Other: _____________________
Signature: ______________________________________________ Date: __________________