SKIN Medical Spa offers cosmetic laser surgery located in bay Area right at the heart of San Francisco at 1825 Union Street

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Last Name:*

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Occupation:

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Marital Status:

Children:

Date of Birth:*

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Address:*

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Home Phone:*

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How did you hear about us?*

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SKIN COLOR:

White

Brown

Black

CHARACTERISTICS:

Always burns, never tans

Usually burns, tans less than average

Sometimes mild burns, tans about average

Rarely burns, tans more than average

Rarely burns, tans profusely

Never burns, deeply pigmented

What is your ethnicity?* (ie: Irish, Native American) **This is important for us to determine appropriate treatment setting**

Do you use sunscreen products regularly? Please select an item.
(Please choose which one:)

Do you go to a tanning salon? Please select an item.

Do you use self tanning products? Please select an item.

Are you pregnant or lactating?

Are you trying to become pregnant?

Did you get hyperpigmentation or masking during pregnancy?

Are you menopausal?

When was the date of your last menstrual period?

**REMINDER: All Questions Require an Answer. Please answer all of the questions in full so we can better treat you.**

Have you ever been on Accutane? Please select an item.
(If yes, when were you on it?)

What medications are you currently taking?* **This section is required. If you are not on any current medications, please put 'N/A'**

Have you taken any other medications in the last 7 days?* **This section is required. If you have not taken any medications in the past 7 days, please put 'N/A'**

Have you used any of ANY of the following topical medications in the past 7 days?

Do you get cold sores, fever blisters or herpes outbreak? Please select an item.
(If yes, how many per year?)

Do you have any Autoimmune or neurological disorders? Please select an item.
(ie: multiple sclerosis, guillain-barre disease; If yes, please explain)

Past medical history - please list* (ie: hypertension, diabetes, other) **This section is required. If you do not have anything in your medical history, please put 'N/A'**

Any allergies to medications, skin allergies? Explain:

Have you had any other cosmetic surgeries or procedures? Please select an item.
(If yes, please explain)

Fine Lines and Wrinkles

Crows Feet

Excess Hair

Sagging Skin

Laugh lines / Folds around mouth

Excess Underarm Sweating

Skincare

Age Spots / Freckles

Acne

Broken capillaries on face or body

Large Pores

Rosacea / Facial redness

Leg Veins

Spider Veins

Other:

If you could change one thing about your skin, what would it be?

Have you ever been to a dermatologist? Please select an item.
(If yes, when and for what purpose)

Have you or any member of your family had skin cancer? Please select an item.
(If yes, who?)

Do you take Herbs? Please select an item.
(If yes, please list)

Have you ever had laser surgery? Please select an item.
(If yes, when was your last one?)

Have you had a Microdermabrasion? Please select an item.
(If yes, when was your last one?)

Have you ever had an acid peel? Please select an item.
(If yes, when was your last one?)

Have you ever had collagen or other fillers? Please select an item.
(If yes, when was your last one?)

Please identify the names of the products you currently use:

Cleanser

Moisturizer

Exfoliant

Sunscreen

Toner

Eye Cream

Night Cream

Glycolic Products

How often do you experience breakouts?

Frequently

Occasionally

Rarely