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?

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
Photosensitivity to Sunlight  
Anemia Electrolysis
Varicose Veins    
Heart Disease/Murmur  
Laser Treatment   
Embolism/Blood Clot  
Tattoos or permanent makeup   
Chemical Peel  
Mental Illness  
Migraine Headaches   
Botox/Dermal Filler  
High Blood Pressure  
Collagen Disease    
Lupus, Schleroderma  
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?  

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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Document name: Medical Evaluation and Physicians Order for Services
lock iconUnique Document ID: 5eaf0a8e2a6a6f2ec6f03d0930f648518fde2630
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May 14, 2020 1:25 pm PDTMedical Evaluation and Physicians Order for Services Uploaded by Skinlogic Med Spa - IP