New Patient formNew Patient Form For Cosmetic Injectables123456 Patient Information SheetPatient Name:*Today’s date:* MM slash DD slash YYYY Date of Birth:* MM slash DD slash YYYY Sex:* Male FemaleAddress*City:* City State:* State Zip: ZIP Cell Phone :*Occupation:Email Address:* Emergency contact name:*Emergency contact Relationship:*Emergency contact Phone :*How do you prefer to receive appointment confirmations?* Phone Call Text Message EmailHow did you hear about us?*Medical HistoryAre you receiving care from other health care professionals? Yes NoIf yes, please name them and their specialty:Please list any drugs or medications you are taking: Please list any vitamins/herbs/homeopathies/other you are taking: Medication Allergies:Cosmetic Allergies:Latex/Other Allergies:Previous Proceduresif YES list date/areaChemical Peel Yes NoInjectables/Fillers Yes NoTattoo/Permanent Makeup Yes NoWaxing/Hair Removal Yes NoFacial Surgery Yes NoMicrodermabrasion Yes NoLesion/Mole Removal Yes NoSuperficial Metal or other Implants Yes NoMicroneedling Yes NoLesion/Mole Removal Yes NoDo you or have you ever had any of the following conditions?Check all that apply:AIDS/HIV Yes NoAnemia Yes NoArthritis Yes NoAuto Immune Disorder Yes NoAsthma Yes NoBleeding Disorder Yes NoBlood Disease Yes NoBlood Transfusion Yes NoCancer (Chemo/Radiation) Yes NoDiabetes Yes NoDizziness Yes NoEpilepsy/Seizures Yes NoEczema Yes NoFainting Yes NoHay Fever Yes NoHeart Disease Yes NoHepatitis Yes NoHigh Blood Pressure Yes NoInfection (active) Yes NoKeloid/Hypertrophic Scars Yes NoKidney Disease Yes NoLiver Disease Yes NoMelanoma Yes NoMental Disorder Yes NoNeuromuscular Disorder Yes NoPhotosensitive Conditions Yes NoPigmentation Disorder Yes NoPorphyria Yes NoPsoriasis Yes NoRespiratory Issues Yes NoSkin Disease Yes NoSkin Cancer Yes NoSinus Problems Yes NoStomach Problems Yes NoStroke Yes NoThyroid Disease Yes NoOther Yes NoHave you ever had:Cold Sores/Herpes/Fever Blisters/Shingles Yes NoHave you ever or are currently using:Retin-A, Renova, Retinoic Acid Products Yes NoSteroids Yes NoRoaccutane(Accutane), Isotretinoin, Sotret, Claravis, Amnesteen, Absorica, Epuris, Isotroin Yes NoPacemaker/Internal Defibrillator Yes NoPrescription Acne Medication Yes NoRadiation Treatment Yes NoBirth Control Pills Yes NoChemotherapy Yes NoAre you Currently:Pregnant Yes NoBreastfeeding Yes NoTrying to become Pregnant Yes NoTan/using self-tanners Yes NoTaking Aspirin or Blood Thinners Yes NoUntitled* The above information is accurate to the best of my knowledge.