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? 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?
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Document Name: Medical Evaluation and Physicians Order for Services
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