Aesthetic Intake Form - Cosmetic Doctor 4 U

Date of Form Completion*

Name*

First Last

Age*

Address

Street Address Address Line 2 City Postcode

Mobile Phone*

OK to Contact

Yes

Leave Message

Yes

Home Phone

OK to Contact

Yes

Leave Message

Yes

Work Phone

OK to Contact

Yes

Leave Message

Yes

Email*

OK to Contact

Yes

Occupation

How did you hear about us?

In order of importance, please rank what you would like to see improved in your skin:

Please drag and drop the below to rank them in order of importance.

Reduction of wrinkles and fine lines
Reduction of brown spots/sun damage
Reduction of oil/acne
Reduction of Hair
Reduction of redness
Tattoo Removal

Anything other than the above that you would like to improve in your skin?

Medical History

For minors, please request Guardian information form.

Is it possible that you may be pregnant?*

Yes
No

Are you breastfeeding?*

Yes
No

Do you form thick or raised scars from cuts or burns?*

Yes
No

After injury to the skin (such as cuts/burns) do you have:*

Darkening of the skin in that area (hyperpigmentation)
Lightening of the skin in that area (hypopigmentation

Hair removal by plucking, waxing, electrolysis or depilatory creams in the last 4 weeks?*

Yes
No

Tanning (tanning bed) or sun expose in the last 4 weeks?*

Yes
No

Tanning products or spray on tan in the last 2 weeks?*

Yes
No

Do you have a tan now in the area to be treated?*

Yes
No

Do you use sunscreen daily with SPF 30 or higher?*

Yes
No

Have you ever had a skin cancer?*

Yes
No

Please detail the type of skin cancer:*

List your common outdoor activities:*

Have you ever had a photosensitive disorder? (e.g. Lupus)*

Yes
No

Do you have a personal history of seizures?*

Yes
No

Permanent make-up or tattoos?*

Yes
No

Where are the tattoos?*

Have you used Accutane in the last 6 months?*

Yes
No

Are you currently taking any antibiotics?*

Yes
No

Which antibiotics are you taking?*

Are you using Retin-A or Glycolic products?*

Yes
No

What is the name of your regular physician:*

Do you have an allergy or sensitivity to any of the following?

Lidocaine
Latex
Sulfa Medications
Hydroquinone
Aloe
Bee Stings

Life threatening allergy to anything?*

Yes
No

What do you have a life threatening allergy to?*

Do you currently smoke?*

Yes
No

Do you have scars on the face?*

Yes
No

Please check all medical conditions past or present

Other illness, health problems or medical conditions not listed:

Consent Agreement*

By ticking this box you consent for Private Doctor 4 U to process the personal data that you have provided. You may withdraw this consent at any time. For more details on how your data is processed, stored and shared see our Privacy Policy

Accurate Information Confirmation*

I certify that the information I have given is complete and accurate.