Name:                                                                                                           DOB:   _______________          Age: ______
Address: ___________________________________________       City: _______________            St: ___        Zip:               
Email address:                                                                                             Primary Telephone:    ____________________             
Are you interested in receiving practice promotions? ____________________________
Who may we thank for referring you?    __________________________________________________________
PERSONAL DATA:    Primary Care Physician: _______________________________________________                
PHARMACY NAME__________________________________________ LOCATION_________________________ PHONE NUMBER___________________
The web is becoming a key way patients learn about our practice.  Do you participate in any of the following?       Facebook         RealSelf        Google
If you are a minor, who will be responsible for your account?
Name: ______________________________________ Relationship to minor: ________________ DOB: _____________ DL # _____________________
Telephone #: __________________________ Address (if different from above):  _______________________________________________                        
 PLEASE CHECK IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING:
⃝   Cold sores/Herpes     ⃝   Hepatitis       ⃝   Photosensitive Disorder       ⃝   Diabetes     ⃝   Sensitive to Anesthetic      ⃝   Lupus    ⃝ Hypertension     
⃝   Heart Problems          ⃝   Autoimmune Illness   ⃝   Irregular Menses     ⃝  Menopause     ⃝   Hysterectomy             ⃝  Hives          ⃝   Keliods  
PAST SURGICAL HISTORY: __________________________________________________________________________________    
MEDICATIONS: _____________________________________________________________________________________________
ALLERGIES:  YES OR NO   if yes, please explain                                                                                                                                                                                             
COSMETIC SURGERY: __________________________________________________________________________________________________________
Have you ever used Retin-A?   Yes or No If yes, what strength?                                                                                     
Have you ever used Hydroquinone (Skin Lightener)?  Yes or No
Have you ever used Accutane?   Yes or No If yes, when?                                                                                                 
If you answer yes to the following please explain
Skin Cancer   Yes or No          Use of Acne Products/Drugs     Yes or   No         Chemical Peels   Yes or No
                                Hypersensitivity to Skin Products    Yes or No      Laser skin resurfacing    Yes or No          Skin Infections    Yes or No  
    
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