AFFZ11 Initial Consultation Form

Welcome to Affiliated Dermatologists, S.C. Skin and Laser Center
Initial Consultation
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Referring Physician
To provide you with the most appropriate skin renewal treatment, we would appreciate your time in completing the following information:
Areas of Interest
Areas of Interest - Check all that apply:

Chemical PeelsExtractionsMicrodermabrasionMicro-needling/CITPhoto Rejuvenation/ IPLDermaplaningProducts/MakeupDiamond GlowSoftwave Laser Hair Removal/Area
Skin Assessment
Skin Assessment - Check All That Apply:

AcneBrown SpotsBlackheadsClogged/Enlarged PoresDry PatchesExcessive OilinessFrecklesHard Bumps under skinMiliaPimples - OftenPimples - SometimesSun DamageUpper Lip Lines - DeepUpper Lip Lines - FineVisible Broken Blood VesselsWrinkles - DeepWrinkles - FineWhiteheads
Type of Skin

DryNormal/CombinationOily
Skin Care Regime

Please check the products you are currently using and list the Brand Names:

	Check all that you are currently using	Brand Name of Product
Cleanser
Eye Cream
Moisturizer
Night Cream
RX Topical
Scrub
Serum
Sunscreen
Toner
Other

Skin Type
Which of the following best describes your skin type?

I - Always burns, never tansII - Always burns, sometimes tansIII - Sometimes burns, sometimes tansIV - Always tansV - Hispanic, Asian, Mediterranean, Middle EasternVI - Black
Ethnicity
Ethnicity

African AmericanAsianEnglishFrenchGermanGreekHispanicIrishItalianMediterraneanMiddle EasternNative AmericanScandinavianOther
MEDICAL HISTORY

Do you have any of the following?

	Check all that apply	Details
Accutane in the last 12 months
Asthma
Bleeding Disorder
Cold sores - Specify Date in Details Column
Current Chemotherapy
Diabetes
Flat warts
Heart Attack
Heart Murmur
Hepatitis
High Blood Pressure
HIV
Hormone Issues
Immune Deficiency
Keloid scarring
Lupus
Melanoma
Pacemaker/Defibrillator
Permanent makeup/tattoos
Phlebitis
Pigmentation Disorder
Polycystic Ovarian Syndrome
Skin Cancer
Smoker - If so, how long? Specify in Details Column
Thyroid
Tuberculosis

Other Medical Conditions - Please explain
Allergies
Current Medications - including over the counter, herbal, or natural supplements
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Patient Signature*

Clear
Date*

MonthDayYear
Date
FOR TECHNICIAN USE

Notes:

Recommendations:

Samples Given:

Staff:
Should be Empty: