AFFZ01 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
In order 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:

MicrodermabrasionDermaplaningChemical PeelsExtractionsCollagen Induction Therapy/ Micro-needlingPhoto Rejuvenation/ IPLProductsMake-Up Laser Hair Removal/Area
Skin Assessment
Skin Assessment - Check All That Apply:

Sun DamageBrown SpotsUpper Lip Lines - DeepUpper Lip Lines - FineFrecklesWrinkles - DeepWrinkles - FineBlackheadsWhiteheadsHard Bumps Under SkinMiliaClogged/Enlarged PoresExcessive OilinessAcnePimples - OftenPimples - SometimesDry PatchesVisible Broken Blood Vessels
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
Toner
Serum
Moisturizer
Eye Cream
Night Cream
Sunscreen
RX Topical
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

MediterraneanMiddle EasternAfrican AmericanNative AmericanFrenchGermanEnglishGreekIrishItalianAsianHispanicScandinavianOther
MEDICAL HISTORY

Do you have any of the following?

	Check all that apply	Details
Diabetes
Thyroid
Immune Deficiency
Lupus
Currently undergoing Chemotherapy
High Blood Pressure
Pacemaker/Defibrillator
Heart Murmur
Heart Attack
Kidney Disease
Bleeding Disorder
Phlebitis
HIV
Hepatitis
Polycystic Ovarian Syndrome
Hormone Issues
Asthma
Tuberculosis
Smoker - If so, state how long in Details Column?
Seizures
Skin Cancer
Melanoma
Flat warts
Keloid scarring
Pigmentation Disorder
Accutane w/in 12 mo.
Cold sores - Date of last in Details Column
Permanent makeup/tattoos
Pregnant? Nursing?

Other Medical Conditions - Please explain
Drug Allergies
Other 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: