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Patient
*
Date of Birth
LIST OF ALL ALLERGIES TO MEDICATIONS OR SUBSTANCES
LIST OF ALL MEDICATIONS, VITAMINS, OTC PREPARATIONS OR RECREATIONAL DRUGS YOU ARE CURRENTLY TAKING
LIST ANY ARTIFICAL IMPLANTS, PACEMAKER, ECT
IF YOU REQUIRE ANTIBIOTICS PRIOR TO ANY PROCEDURES, PLEASE EXPLAIN
PERSONAL/CURRENT/PAST HEALTH PROBLEMS
Cancer
NO
YES
-
Ears/Nose/Throat
NO
YES
-
High blood pressure
NO
YES
-
Lungs
NO
YES
-
Arthritis/joints
NO
YES
-
Headaches/seizures
NO
YES
-
Psychological
NO
YES
-
Venereal disease
NO
YES
-
Eyes
NO
YES
-
Heart
NO
YES
-
Liver Disease
NO
YES
-
Stomach/bowel
NO
YES
-
Kidneys
NO
YES
-
Allergic/Immunologic
NO
YES
-
Blood/Bleeding Disorders
NO
YES
-
Other (diabetes,lupus,ect.)
NO
YES
-
MEDICAL HISTORY
Allergies
SELF
MOTHER
FATHER
BLOOD RELATIVE
EXPLAIN
Asthma
SELF
MOTHER
FATHER
BLOOD RELATIVE
EXPLAIN
Diabetes
SELF
MOTHER
FATHER
BLOOD RELATIVE
EXPLAIN
Eczema
SELF
MOTHER
FATHER
BLOOD RELATIVE
EXPLAIN
Skin cancer
SELF
MOTHER
FATHER
BLOOD RELATIVE
EXPLAIN
Other
SELF
MOTHER
FATHER
BLOOD RELATIVE
EXPLAIN
TO BE COMPLETED BY ALL WOMEN
Are you nursing or pregnant?
NO
YES
Are you currently planning a pregnancy?
NO
YES
Are you taking birth control pills?
NO
YES
PLEASE INFORM YOUR PHYSCIAN/NP AT ANY TIME IF YOU BECOME PREGNANT DURING YOUR TREATMENT
Date
*
Phone
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Home
About Us
Testimonials
Services
Facials
Laser
Laser Treatments
Intense Pulse Light (IPL)
Laser Hair Removal
Laser Genesis
Spider Vein Therapy
Carbon Laser Peel
Chemical Peel
Injectables
Microdermabrasion
Platelet-Rich Plasma (PRP) Treatment
Body Contour Treatments
MicroNeedling
Dermal Infusion
Physical therapy
News
Policies
Forms
Laser Treatment Consent Form
Chemical Peel Consent Form
The Perfect Derma Peel Consent
Photography consent form
Neurotoxin Therapy Consent Form
Microdermabrasion Consent Form
MDPen Patient Consent Form
MDPen Home Care Instructions
General Information Form
Filler Consent Form
Patient Medical History
Contact Us
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