Med Spa Intake Form

Name______DOB______

Last Name First Name MI Address______Phone ______

Street City, State, Zip Email______Occupation ______Emergency Contact______How did you hear about us?______What is the main reason for your visit today?______What home skin-care products are you currently using? ____Cleanser _____Exfoliants/Scrubs _____Toner _____Moisturizer _____SPF ____Eye Cream _____Serums _____Retinol _____Soap ____Body Care ____Sunless tanner _____Other Your skin is: ____Oily _____Rosacea _____ Normal ____Dry _____Sensitive ____ Eczema ____T-zone/combination _____Psoriasis _____ Unsure ____Resilient _____Hyperpigmentation/Melasma Have you ever had any cosmetic procedure such as: ____Microdermabrasion _____Facial Surgery _____Plastic Surgery ____Chemical Peel _____Laser Hair Removal _____Other ____Microneedling _____Botox/Injections/Fillers ____Facial Resurfacing _____Photo Facial/IPL/SRA

Do you have a history of: ___Scarring ____Hyperpigmentation ____Keloids _____Herpes/cold sores

How does your skin react to the sun? ___ Always burns ___ Always tans

___ Usually burns, sometimes tans ___ Usually tans, sometimes burns

Ethnic background:______Do you have any significant illness or have you in the past?______List current medications and supplements:______

Allergies______List any sensitivities:______

Personal Health History: ____Use of tanning beds _____Migraines _____Epilepsy/Seizures ____Diabetes _____Communicable disease _____Use of blood thinners/aspirin/NSAIDS ____Metal Implants/Piercings _____Heart Issues ____Pacemakers _____History of Accutane or Retin A

Do you smoke? ___No ____Yes How many glasses of water do you consume per day?______How many caffeinated beverages do you consume per day?______

Hormones-Females Only

____Taking birth control or estrogen ____Going through menopause ____Regular periods Are you on or expecting your menstrual cycle? ___Yes ___No ____During pregnancy, did you ever get hyperpigmentation or melasma? ____Pregnant or Nursing When was your last child born?______Hormones-Males Only Any hormonal imbalance issues?______Have you experienced any ingrown hairs after shaving?______When was the last time you shaved?______The information on this form is correct to the best of my knowledge:

______(please initial) I have read the HIPPA Acknowledgement Form & Notice of Privacy Practice Signature:______Date:______24 hour cancellation policy for appointments * Return policy: Refunds are issued within 30 days of purchase for exchange or credit on a future product or service purchase Did you know, Twin Ports Dermatology also has a Med Spa? Below are the services we offer.

Please circle all that you may be interested in learning more about:

• Botox

• Dermal Fillers

• Chemical Peels

• Permanent Hair Removal

• Kybella

• Skin Rejuvenation

• Sublative Skin Resurfacing

• Face / Body Waxing

• Customized Facial

• Micropen / Micro-Needling

• Latisse

• Jane Iredale Makeup

• Medical Grade Skin Care Products / Supplements

• Complimentary Consultation Please circle all that you may have concerns about:

• Fine Lines

• Wrinkles

• Thin Lips • Sagging Facial Features / Loss of Volume

• Blotchy / Dull Skin

• Acne

• Acne Scarring

• Scarring

• Stretch Marks

• Unwanted Facial Hair

• Unwanted Body Hair

• Sun Spots

• Age Spots

• Facial Veins / Redness

• Lash Length / Fullness

• Double chin

Twin Ports Dermatology offers complimentary consultations. Are you interested in setting up a free consultation to dis- cuss your skin health & customized recommendations? Yes / No