Patient Intake Form New Patient Information Name: Date Of Birth: Address:Apt/Unit #: City:State: Zip Code: Home phone: Cell Phone: Work Phone: Email: How did you hear about us? What services are you interested in? What is your daily home care regimen? Have you ever used any products that caused a bad reaction? Yes No Describe: Are you sensitive to alcohol based products? Yes No Do you have any allergies or sensitivities? Yes No Please list: Do you have Rosacea or broken capillaries? Yes No Are you currently using any Alpha Hydroxy Acids? Yes No Explain: Are you currently using any of the following?   Retina A? Yes No Accutane? YesNo Renova? YesNo Differin? YesNo Tazorac? YesNo Avita? YesNo Prescription Strength Benzoyl Peroxide? Yes No Or any other prescription exfoliant? Please list all medications you are currently using (including antibiotics). Have you had a chemical peel or any procedure with a medical device in the past 14 days? Yes No Explain Have you recently had facial surgery? Yes No How long ago? Describe Do you have any metal bones, pins, plates or pace makers? Yes No Have you recently had laser resurfacing? Yes No When What kind? Do you have permanent make up? Yes No If so, where? Do you currently have a sunburn/windburn/red face? Yes No Are you pregnant or trying to become pregnant? Yes No If yes, are you breast feeding? Yes No Do you smoke? Yes No Do you develop cold sores/fever blisters? Yes No If so, when was your last breakout? Do you participate in vigorous aerobic activity or sports? Yes No What type? Eye Color: Hair Color: Skin tone: Hereditary background: What are cosmetic improvements you would like to see to your skin? Describe your skin? Thick Thin Saggy Firm Normal Dry Combination Oily Acne Acne Scarred Large Pores Small Pores Rosacea Eczema Freckled Sun Damaged Uneven Mature Patchy dryness on: Signature: