Skin Rejuvenation Consent

Patient Information & Medical History

Thank you for choosing The Skin Clinic Medi Spa. Your well being and safety are our concern as we deliver your results driven treatments. Please assist us by completing the following information:

Date ______Reason for visit? ______

Title ______First ______Last ______M.l. ______

Street Address ______Apt# ______

City ______State ______Zip ______

Home Phone ______Cell Phone ______

Work Phone ______Preferred Contact Number ______

Email Address ______

Date of Birth ______Anniversary (optional) ______

Occupation (optional) ______

How did you hear about us? ______

Emergency Contact Name & Number ______

Are you currently under a physician’s care? ______

What if any medications are you taking? ______

Do you use Retin-A? ______Have you used Accutane _____ if yes, when? ______

Please check if you are affected by or have any of the following:

¨ Allergies / ¨ Fever Blisters / ¨ Pigmentation Problems
¨ Asthma / ¨ Herpes/Cold Sores / ¨ Prosthetic Heart Valve
¨ Back Problems / ¨ Heart Condition / ¨ Psychological Problems
¨ Bone or Nerve Injury / ¨ Hepatitis / ¨ Radiation Treatments
¨ Bleeding Problems / ¨ High/Low Blood Pressure / ¨ Sinus Problems
¨ Cancer / ¨ HIV/AIDS / ¨ Skin Diseases/Skin Cancer
¨ Cardiac Arrest / ¨ Immune Disorders / ¨ Skin Rashes
¨ Cellulite / ¨ Keloids/Abnormal Scarring / ¨ Stretch Marks
¨ Claustrophobia / ¨ Lupus / ¨ Suspicious Growths
¨ Diabetes / ¨ Pacemaker / ¨ Thyroid Problems
¨ Eczema / ¨ Photoallergic / ¨ Varicose Veins
¨ Epilepsy / ¨ Poor Wound Healing / ¨ Metal Bone, Pins or Plates

Do you have any allergies? ______

(Please list, ex: Shell Fish, Iodine, Hay Fever, etc.)

Are you pregnant? ______If yes, no. of weeks/months? ______

Do you smoke? ______Do you wear contact lenses? ______

Are you presently under a physician’s care for any current skin condition? ______

Name and number of your physician? ______

Have you ever experienced any form of acne? ______If yes, what age? ______

Do you ever experience any acne breakouts? ______

Please indicate any concerns you have about your skin? ______

______

Would you like to learn about improving your skin with Peak Performance Skin Technologies?

______

Do you go in the sun of tanning booth? ______Do you use SPF ______

Have you ever had or are you considering plastic surgery? ______

Have you ever had Botox and/or facial fillers? ______

If you answered yes to any of the above, please explain ______

______

Is there any additional medical information not listed above that pertains to your current, past or

future health? ______

______

I understand that the service offered at The Skin Clinic Medi Spa are not a substitute for medical care, and any information provided y the staff is not diagnostically prescriptive, which is only intended to provide better service and is completely confidential.

I fully understand and agree to the above statement.

Patients Signature ______Date ______

76 East Main Street Suite 3, Huntington, N.Y. 11743