Consult Intake Form (Page 3 of 4) in pdf

Consult Intake Form Page 3

If so, when was it done? ___________________ What area(s) were treated: ______________________

Do you have any of the following chronic skin disorders? ⃝ Psoriasis ⃝ Fever/Sun Blisters ⃝ Cold

Sores ⃝ Keloid Scarring ⃝ Herpes Simplex/ Blisters

Have you ever undergone any of the following treatments? ⃝ Microdermabrasion ⃝ Photo Facial

⃝ Skin Tightening ⃝ Cosmetic Surgery ⃝ Accutane If yes, explain: __________________________

____________________________________________________________________________________

(Circle all that apply )

Race/Ethnicity: (This information is used to determine skin typing for particular laser procedures)

⃝ American Indian/Alaska Native

⃝ Asian

⃝ African American

⃝ Caucasian/White

⃝ Hispanic/Latino

⃝ Hawaiian/Pacific Islander

⃝ Middle Eastern

⃝ Mediterranean

⃝ Northern European ⃝ Other Race ⃝ Unknown

I verify that the above information is true and accurate to the best of my knowledge.

Signature: _____________________________________________ Date: __________________

Reviewed By: __________________________________________ Date: __________________

2014-01-02

Consult Intake Form Page 3