Patient Intake & Medical Information Form
Full Name
Date of Birth
Age
Gender
Phone Number
Email Address
Home Address
Emergency Contact Name & Number
Please check all that apply.
DiabetesHigh Blood PressureHeart DiseaseThyroid DisorderAutoimmune DiseaseAsthmaSkin Disorders (Eczema, Psoriasis, etc.)CancerAnxiety / DepressionBleeding DisordersNoneOther
Other Medical Condition
MedicationsLatexFood AllergiesSkincare ProductsNoneOther
Other Allergy
Please specify allergies and reactions
Please list all current medications, vitamins, and supplements.
Medication/Supplement
Dosage
Frequency
What are your primary concerns today?
AcneFine Lines & WrinklesHyperpigmentationRosaceaHair LossWeight ManagementHormonal ConcernsScarringSkin TighteningWellness & Anti-AgingOther
Other Concern
Describe your concerns in detail
Do you smoke? YesNo
Do you consume alcohol? YesNo
Water intake per day
Exercise frequency
Average sleep per night
Have you previously received any of the following?
Botox / DysportFillersChemical PeelsLaser TreatmentsMicroneedlingFacialsWeight Loss TreatmentsIV TherapyNoneOther
Other Previous Treatment
Date of last treatment
I certify that the information provided above is true and complete to the best of my knowledge. I understand that withholding medical information may affect treatment results and safety.
I consent to evaluation and treatment by Dermal Wellness Group and authorize the providers to perform recommended procedures after discussing risks, benefits, and alternatives.
I agree to the consent and acknowledgment above.
Patient Signature
Date
Provider Signature
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