Aesthetics New Patient Info Form
Patient Name: Date of Birth:
State: Zip: Gender: MF
Home Phone: Work Phone:
Cell Phone: Email:
Emergency contact: Relationship:
Would you like to receive e-mail updates regarding new productts, procedures or events?
If yes, check one:
How did you hear about our practice?
Check if you are currently, or ever have been, treated for any of the following conditions:
Are you on hormone replacement therapy?
Are you currently pregnant or nursing?
Are you currently using Renova, Retin-A or other retinoid products?
Are you currently using bleaching agents like Hydroquinone?
Are you currently on Accutane or Differin therapy?
Have you had any of the following in the last 7 days: Collagen, Botox, Chemical Peel or Laser Procedure?
What medications are you currently taking?
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Aesthetics New Patient Info Form
Agree & Sign