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Medical Evaluation and Physicians Order for Services

Please Fill out all boxes below.

Emergency Contact

What is your current gender identity?
Male Female Transgender Male Transgender Female Gender Queer Decline to answer

What pronouns do you prefer that we use when talking about you?
He/him/his She/her/hers They/them/theirs

What areas of concern or improvement would you like to see for your skin?
Skin Care Advice Facial Veins Neck Wrinkles Skin Care Products Facial Redness Thin Lips Make-Up Fine lines Wrinkles Blotchy Skin Unwanted Hair Chemical Peel Facial Contouring Brown spots-age spots-freckles Length-fullness of eyelashes Dermal Fillers Drooping brow Facial fullness drooping Drooping eyelids

Interested in other services that Skinlogic Med Spa has to offer -e.g. laser, microneedling, advanced peels, facials

Have you ever been or are you currently under the care of a dermatologist?

Health History/History Pertinent to Cosmetic Procedures
If NO do not fill out but if YES click drop down menu and give dates and further information. Do you have or have you ever had:

Cancer/Skin Cancer
Do you have herpes?
Do you have any auto immune diseases?
Regular Sun/Tanning Exposure
Diabetes
Photosensitivity to Sunlight
Jaundice
Waxing/Plucking
Anemia Electrolysis
Varicose Veins
Microdermabrasion
Heart Disease/Murmur
Laser Treatment
Embolism/Blood Clot
Tattoos or permanent makeup
Asthma
Chemical Peel
Mental Illness
Sclerotheraphy
Migraine Headaches
Botox/Dermal Filler
High Blood Pressure
Vitiligo
Collagen Disease
Lupus, Schleroderma
Keloid/Scarring
Chronic Skin Disorder
Use of Acutane for Acne
Seizure Disorder
Use of Gold Theraphy for arthritis
Neurological Disorder
Pacemaker/Defibrillator/Implant in
Immunological Disease -treatment area
Do you smoke?
Have you ever smoked?
Are you pregnant or trying to get pregnant?
Are you breastfeeding?

Environmental Allergies
Allergies to Medications
Allergy to Latex

Surgeries you have had:

Current Medications/Supplements:

Is there anything you would like our treatment providers to know before your treatment?

Fitzpatrick Skin Type Form

What is your Ethnicity?

Score	0	1	2	3	4
What is your eye color?	Light Blue, Gray, green	Blue-Gray, green	Blue	Dark Brown	Brownish Black
What is the natural color of your hair	Sandy Red	Blond	Chesnut/Dark Blond	Dark Brown	Black
What is the color of your skin(non- exposed areas)?	Reddish	Very Pale	Pale with Beige Tint	Light Brown	Dark Brown
Do you have freckles on unexposed areas?	Many	Several	Few	Incidental	None

Please total your score for Traits:

Score	0	1	2	3	4
What happens when you stay too long in the sun?	Painful redness, blistering, peeling	Blistering, followed by peeling	Burns sometimes followed by peeling	Rare burns	Never had burns
To what degree do you turn brown?	Hardly or not at all	Light color tan	Reasonable tan	Tan very easy	Turn dark brown quickly
Do you turn brown within several hours of exposure?	Never	Seldom	Sometimes	Often	Always
How does your face react to the sun?	Very Sensitive	Sensitive	Normal	Very Resistant	Never had a problem

Please total your score for Sun Exposure:

Score	0	1	2	3	4
When did you last expose your body to the sun (or tanning bed/tanning cream?	More than 3 months ago	2-3 months ago	1-2 months ago	Less than a month ago	Less than 2 weeks ago
Did you expose the area to be treated to the sun?	Never	Hardly Ever	Sometimes	Often	Always

Please total your score for Tanning Habits:

___________________________________________________________________________________________________________

Please add the total of the 3 boxes above and select the checkbox for the corresponding total.

0-7

8-16

17-24

25-30

Over 30

Your Fitzpatrick Skin Type:

Skin Type Score	Fitzpatrick Skin Type
0-7	I
8-16	II
17-24	III
25-30	IV
Over 30	V

Cancellation Policy:

Your allocated appointment times are reserved especially for you and are very important to us. We have implemented this cancellation policy because we value the business of our clients and the time of our staff. All of our policies are designed to benefit our current clients and our future clientele. Therefore, we respectfully request at least 24 hours’ notice for adjustments to your appointments and for cancellations. Please understand that when you forget or cancel your appointment without giving enough notice, we miss the opportunity to fill that appointment time and clients on our waiting list miss the opportunity to receive services they need.

I understand that as a new or current client of Skinlogic Med Spa that I supply a credit card to have on our files. All cards on file are added to the system via a secure electronic process that ensures the information is encrypted and remains secure. In the event that we do not receive the required 24 hour notice for adjustments and cancellations a $50 fee will be applied to your card.

I have read the above Cancellation Policy and agree to its terms and conditions. I hereby give my consent for Skinlogic Med Spa to securely store my credit card on file and authorize Skinlogic Med Spa to charge my card if I cancel less than 24 hours before any future scheduled appointments.

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May 14, 2020 1:25 pm PDT

Medical Evaluation and Physicians Order for Services Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 67.168.123.88