Best Cosmetic Dermatology Clinic –
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Coolsculpting
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Acne Scar / Accidental Scar Reduction
Botulinum Toxin
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Facelift with Threads
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Laser Hair Removal
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Keravive Hair Treatment
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PRP (Platelet Rich Plasma) Treatment
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Chemical Peels
Hair Treatment
Medi Facials
Nonsurgical Facelift
Non-surgical Body Sculpting with FYFO- Freeze your Fat Off
Treatments
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Others
Contact Us
Menu
Home
About
Body
Open menu
Back Rejuvenation
Coolsculpting
Cellulite Reduction
Laser Hair Removal
Skin Lightening
Stretch Marks Reduction
Radio Frequency
Tattoo Removal
Face
Open menu
Acne Scar / Accidental Scar Reduction
Botulinum Toxin
Chemical Peel
Double Chin Reduction
Facelift with Threads
Fillers
High-Intensity Focused Ultrasound / HIFU
Hydrafacial
Laser Hair Removal
Medifacials
Skin Brightening
Hair
Open menu
Growth Factor Concentrate
Keravive Hair Treatment
Mesotherapy
PRP (Platelet Rich Plasma) Treatment
Packages
Services
Open menu
Chemical Peels
Hair Treatment
Medi Facials
Nonsurgical Facelift
Non-surgical Body Sculpting with FYFO- Freeze your Fat Off
Treatments
Wellness Health Checkups
Others
Contact Us
Call Now
Asthetic Medical History Form
Asthetic Medical History Form
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First Name
Last Name
Date of Birth
Gender
Male
Female
Address
Address Line
City
State
Zip Code
Email
Mobile Number
Family Doctor
Pharmacy
Emergency Contact Person Name
Phone Number
How did you find out about us?
Which body area(s) or condition would you like treated?
Please answer each of the following questions:
Do you have ANY allergies to medications, foods, latex, orother substances? Please List:
Do you smoke?
Yes
No
Average per day?
Do you have ANY current or chronic medical conditions? YES / NODisclose any history of heat urticaria, diabetes, autoimmunedisorder or any immunosuppression, blood disorders, cancer,bacterial or viral infections, medical conditions that significantlycompromise the healing response, skin photosensitivitydisorders, or any other condition or illness.
Yes
No
Please List:
Do you have ANY current or chronic skin conditions? YES / NOAlso disclose any history of vitiligo, eczema, melasma, psoriasis,allergic dermatitis, any diseases affecting collagen includingEhlers-Danlos syndrome, scleroderma, skin cancer, or any otherskin condition.
Yes
No
Please List:
Are you under a doctor’s care?
Yes
No
If so, for what?
Do you take ANY medications (prescriptions or non- YES / NOprescriptions) including vitamins and herbal supplementson a regular basis?
Yes
No
Please List:
Are there any topical products (both medical and non-medical) that you use on your skin on a regular or daily basis?
Yes
No
Please List:
Are you taking oral steroids (eg. prednisone, dexamethasone)?
Yes
No
Do you have a pacemaker or external defibrillator?
Yes
No
Do you have any metal implants under the area being treated?
Yes
No
Do you have a history of light-induced seizures?
Yes
No
Do you have a history of Herpes in the area being treated?
Yes
No
Do you have any open sores or lesions?
Yes
No
Have you had radiation therapy in the area being treated?
Yes
No
Do you have a history of keloid scaring or hypertrophic scar formation?
Yes
No
In the last 6 months, have you used any of the following? Anticoagulants or blood-thinning medications, photosensitizing medications or anti-inflammatories?
Yes
No
List Product, Date Used:
In the last 3 months, have you used any of the following products: glycolic acid or other alphahydroxy- or betahydroxyacid products, exfoliating or resurfacing products or treatments?
Yes
No
List Product, Date Used:
Have you had any cosmetic procedures in the past 6 months?
Yes
No
Have you had any permanent make-up, tattoos, implants, or fillers, including but not limited to collagen, autologous fat, Restylane, ect.?If yes, please list locations and dates:
In the last month, have you been treated with any Botulinums (eg. Botox or Dysport)?
Yes
No
If yes, please list:
Have you taken Accutane (or products containing isotretinoin) or Tretinoin (eg. Retin-A, Renova) in the last 6 months?
Yes
No
Have you had any unprotected sun exposure, used tanning creams (including sunless tanning lotions) or tanning beds/lamps in the last month?
Yes
No
For Women Only:
Are you pregnant or breastfeeding?
Yes
No
Are your menstrual periods regular?
Yes
No
Have you been diagnosed with Polycystic Ovarian Disorder?
Yes
No
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