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? She/her/hers He/him/his 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
If YES, when and for what condition/treatment?
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:
YES Cancer/Skin Cancer YES Regular Sun/Tanning Exposure YES Diabetes YES Photosensitivity to Sunlight YES Jaundice YES Waxing/Plucking YES Anemia YES Electrolysis YES Varicose Veins YES Microdermabrasion YES Heart Disease/Murmur YES Laser Treatment YES Embolism/Blood Clot YES Tattoos or permanent makeup YES Asthma YES Chemical Peel YES Mental Illness YES Sclerotheraphy YES Migraine Headaches YES Botox/Dermal Filler YES High Blood Pressure YES Vitiligo YES Collagen Disease YES Herpes/Cold Sore/Sun Blisters YES Lupus, Schleroderma YES Keloid/Scarring YES Chronic Skin Disorder YES Use of Acutane for Acne YES Seizure Disorder YES Use of Gold Theraphy for arthritis YES Neurological Disorder YES Pacemaker/Defibrillator/Implant in YES Immunological Disease -treatment area
NOYESDo you smoke? NOYES Have you ever smoked? NOYES Are you pregnant or trying to get pregnant? NOYES Are you breastfeeding?
NOYES Environmental Allergies NOYES 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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