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? 

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.

 

Issues in signing document?  Scroll up to see required areas marked in red that you need to fill out then re-sign.

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Medical Evaluation and Physicians Order for Services
lock iconUnique Document ID: d80490752b02f157d7ca504a710e218c7c3b0f9b
Timestamp Audit
May 14, 2020 1:25 pm PSTMedical Evaluation and Physicians Order for Services Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 154.9.128.131