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 67.183.34.85