New Patient Form

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Patient Name*
Please enter a number from 1 to 120.
MM slash DD slash YYYY
Home Address*
Please list all medications which you are currently taking or have used in the past 6 months. For each medication, please include the drug name, your dose, and frequency. Be sure to include any of the following: birth control pills, aspirin or ibuprofen containing drugs, weight loss medications, Coumadin or any blood thinning medication, prescription eye drops, steroids.
Past Personal Skin History
Please check all that apply.
Medical History*
Please check all of the following medical conditions you now have or have had in the past.
If you checked any conditions above, please provide additional details here.
Are you pregnant or lactating?*
Do you have a history of herpes simplex (cold sores)?*
Do you have a history of developing keloids (raised scars)?*
Have you ever been diagnosed with Vitiligo (pigment loss in the skin)?*
Have you ever seen a dermatologist for your skin?*
Do you use any form of Retin-A, Glycolic Acid or Salicylic Acid?*
Have you ever been on Accutane?*
Have you ever had Botox™ or Dermal Filler injections?*
Have you ever had a bad reaction to any skin care products?*
Do you use a sunscreen?*
Do you have a history of atypical moles, melanoma or skin cancer in yourself or family?*
Have you or anyone in your family ever had unusual reactions to topical anesthetics (numbing cream)? YES / NO*

I acknowledge that I have disclosed my complete medical history and the above is a complete and accurate representation of my medical and psychological status.

This field is for validation purposes and should be left unchanged.