Patient Consent Form - Eclipse Aesthetics (Page 2 of 4) in pdf

Patient Consent Form - Eclipse Aesthetics Page 2

PATIENT'S MEDICAL HISTORY

Date of birth:

Current date:

First name:

Last name:

Home address:

Mailing address:

Personal phone:

Business phone:

Employer:

Profession:

Are you currently or have you been under any medical treatment these last 2 years?

Please write the name of your regular doctor and his/her phone number:

Emergency contact person:

Phone:

Please list the medicines you are currently taking, including: Retin A, Glycolic acid, Accutane, etc.

Please list all your allergies to medication or antibiotic, food allergies and skin allergie (included soaps

and cleansing creams).

What products do you use as skin care product?

Have you been in one of the following condition:

(Please answer by YES or NO):

______ Abnormal cardiac condition

______ Any type of cancer

______ Sore due to coldness

______ Tumor, Cyst or Growth

______ Herpes

______ Are you pregnant ?

______ Hemophilia

______ Hepatitis

______ High or Low blood pressure

______ Do you smoke ?

______ Prolonged bleeding

______ Circulatory problem

______ Epilepsy

______ Diabetes

______ Dizziness or Fainting

______ Eyes drop ?

______ Chemiotherapy or Radiation

______ Laser Treatment

______ Lupus or Autoimmune disease

Have you ever had a hyperpigmentation (darkening of the skin) or a hypopigmentation (lightening of

the skin) of your skin due to injury?

Are you currently taking aspirin or ibuprofen

YES / NO

Signature

Date

Patient Consent Form - Eclipse Aesthetics Page 2

Related Articles

Related forms

Related Categories