Medical Evaluation and Physicians Order for Services
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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?NOYES
Health History/History Pertinent to Cosmetic ProceduresIf 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 areaNOYESDo you smoke? NOYES Have you ever smoked? NOYES Are you pregnant or trying to get pregnant? NOYES Are you breastfeeding?
Environmental Allergies Allergies to Medications NOYES Allergy to Latex
Surgeries you have had:
Is there anything you would like our treatment providers to know before your treatment?
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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Document Name: Medical Evaluation and Physicians Order for Services
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