Medical Evaluation and Physicians Order for Services


Please Fill out all boxes below.

    
 

 

Emergency Contact    

What is your current gender identity?

What pronouns do you prefer that we use when talking about you?

What  areas of concern or improvement would you like to see for your skin?

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

If YES, when and for what condition/treatment?  

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
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   
Herpes/Cold Sore/Sun Blisters         
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? 

Leave this empty:

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Document name: Medical Evaluation and Physicians Order for Services
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May 14, 2020 1:25 pm PDTMedical Evaluation and Physicians Order for Services Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 173.160.193.254