BE BEAUTIFUL MEDICAL

Intake Form

Intake
Date of birth
Your address
Checkboxes
Checkboxes
Checkboxes
Checkboxes
I would like to receive a newsletter and information about special promotions
Are you using Retin-A or Glycolic products?
Do you have a tan now in the area to be treated?
Do you use sunscreen daily with SPF 30 or higher?
Permanent make-up, microblading or tattoos?
Have you ever had a photosensitive disorder? (ie: lupus)
Have you ever had skin cancer?
Do you have poor healing?
Does your skin get lighter when injured (hypopigmentation)?
Does your skin get darker when injured (hyperpigmentation)?
Do you have any scars on the face?
Are you pregnant or breastfeeding?

Do you have the following medical problems?

Keloid scars
Bleeding Disorder
Thyroid imbalance
Liver problems
Seizures
Shingles
Diabetes
Eczema
Heart Condition
Psoriasis
Pacemaker
Skin disorder
Implants / shunts
Seasonal allergies/allergic rhinitis
Cancer
Cold Sores
Autoimmune disease (ie: Rheumatoid arthritis, Scleroderma)
Disease of nerves or muscles (ie: ALS, Myasthenia gravis, Lambert-Eaton or other)
Collagen vascular disorder
Stroke
Asthma or COPD
High blood pressure
Hepatitis
Mental illness
HIV/AIDS
Menopause

Are you currently taking any antibiotics?
Have you used Accutane in the last 6 months?
Do you have any allergies?
Are any of your allergies life-threatening?
Do you have any allergies to metal?

Do you drink alcohol?
Do you currently smoke?

Main reason for your visit

Which three statements best reflect how you would like to look and feel after treatment?
How would you rate the quality of your skin?
If you could enhance an aspect of your skin, what would it be?
These treatments/products interest me: (Please check the treatment area(s) that interest you)
How did you hear about us