Hydrafacial Patient Application

General

FirstName:

LastName:

Date:

Age:

Address:

City:

State:

Zip Code:

Phone Home:

Phone Work:

Phone Cell:

Date of Birth:

Marital Status:

Employer:

Occupation:

Emergency Contact:

Relationship:

Emergency
Phone Home:

Emergency
Phone Work:

Emergency
Phone Cell:

Email Address:

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Health History

Medications:

(prescription and over the counter; vitamins, herbal medications)

Allergies:

Surgeries
/Dates:

Are you?

Pregnant:

Yes No

Nursing:

Yes No

Do you?

Smoke:

Yes No

Drink Alcohol:

Yes No

Amount per day:

Skin Type

(1) Highly sensitive, always burns, never tans. Ex: Red hair with freckles
(2) Very sun sensitive, burns easily, tans minimally. Ex: Fair skinned, fair haired Caucasians
(3) Sun sensitive skin, sometimes burns, slowly tans to light brown. Ex: Darker Caucasians
(4) Minimally sun sensitive burns minimally, always tans to moderate brown. Ex: Mediterranean type Caucasians.
(5) Sun insensitive skin, rarely burns, tans well. Ex: Some Hispanics and blacks.
(6) Sun insensitive skin, never burns, deeply pigmented. Ex: Darker Blacks.

The above information is true and accurate to the best of my knowledge.

Patient Signature:

Date: