Name (Last, First):*
Phone Number*
DOB (YYYY/MM/DD):*
PHN:*
Email*
Family doctor:
Name and Relationship to you:
Emergency Contact Phone #:
(Acne, Dry Skin, Eczema, Skin Cancer, Rosacea, Hair Loss, etc.)
(HIV, hepatitis, stroke, Sheart attack, diabetes, blood clotting, pacemaker, keloid scars, etc.)
(Procedures and Operations). Please include approximate dates
Do you smoke?YesNo
Do you drink alcohol?YesNo
Do you use recreational drugs? YesNo
Do you exercise? YesNo
Are you pregnant? YesNo
Are you on blood thinners? YesNo
Have you ever used tanning beds? YesNo
Do you use sunscreen? YesNo
Have you ever had a blistering sunburn? YesNo
When was your last skin check?
Have you had excisions before? YesNo
1.
2.
Patient Signature*:
Date*:
If a concern is not treatable under MSP, would you be interested in any aesthetic procedures which would be privately paid for (treatment for pigmentation, rejuvenation, benign mole removal, etc)? YesNo
