<p>Med Spa Intake Form</p><p>Name______DOB______</p><p>Last Name First Name MI Address______Phone ______</p><p>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</p><p>Do you have a history of: ___Scarring ____Hyperpigmentation ____Keloids _____Herpes/cold sores</p><p>How does your skin react to the sun? ___ Always burns ___ Always tans</p><p>___ Usually burns, sometimes tans ___ Usually tans, sometimes burns</p><p>Ethnic background:______Do you have any significant illness or have you in the past?______List current medications and supplements:______</p><p>Allergies______List any sensitivities:______</p><p>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</p><p>Do you smoke? ___No ____Yes How many glasses of water do you consume per day?______How many caffeinated beverages do you consume per day?______</p><p>Hormones-Females Only</p><p>____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:</p><p>______(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. </p><p>Please circle all that you may be interested in learning more about:</p><p>• Botox</p><p>• Dermal Fillers</p><p>• Chemical Peels</p><p>• Permanent Hair Removal</p><p>• Kybella</p><p>• Skin Rejuvenation</p><p>• Sublative Skin Resurfacing</p><p>• Face / Body Waxing</p><p>• Customized Facial</p><p>• Micropen / Micro-Needling</p><p>• Latisse</p><p>• Jane Iredale Makeup</p><p>• Medical Grade Skin Care Products / Supplements</p><p>• Complimentary Consultation Please circle all that you may have concerns about:</p><p>• Fine Lines</p><p>• Wrinkles</p><p>• Thin Lips • Sagging Facial Features / Loss of Volume</p><p>• Blotchy / Dull Skin</p><p>• Acne</p><p>• Acne Scarring</p><p>• Scarring</p><p>• Stretch Marks</p><p>• Unwanted Facial Hair</p><p>• Unwanted Body Hair</p><p>• Sun Spots</p><p>• Age Spots</p><p>• Facial Veins / Redness</p><p>• Lash Length / Fullness</p><p>• Double chin</p><p>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</p>