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:

Laser Hair Removal/Area
Skin Assessment
Skin Assessment - Check All That Apply:
Type of Skin
Skin Care Regime

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

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

Do you have any of the following?

Rows	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:
Patient Signature

Clear
Date

MonthDayYear
Date
FOR TECHNICIAN USE

Notes:

Recommendations:

Samples Given:

Staff:
Should be Empty: