PATIENT REGISTRATION FORM - Precision Aesthetics Medical Group

Patient Name*

First Last

Patient Email*

Patient Address*

Street Address Address Line 2 City State ZIP Code

Date of signup

I want to receive promotions and email communications

Yes

Patient Occupation*

Patient Phone*

This phone is my

Cell
Home
Office

Patient Date of Birth*

Patient Age

How did you hear about us?

Marital Status

Single
Married
Divorced
Widowed

Sex

Male
Female

Emergency Contact*

Emergency Contact Phone*

Interests/Concerns

Botox
Kybella (double chin)
Fillers
Skincare Products/Peels (skin pigmentation, fine lines, skin texture)
Laser Treatments (skin pigmentation, fine lines, skin texture)
Latisse (lengthen, fill in lashes)
Microneedling (fine lines, wrinkles, acne scars, tightening)

Choose all that apply.

Have you ever had any of the following in the past?

Botox
Fillers
Latisse
Laser Treatments

Choose all that apply.

If so, when was your last treatment?

Do you have skin care products that you prefer? Please list:

Any likes or dislikes about past treatments?

Are you happy with your skin?

Yes
No

If "no" to above question please explain

Medical History/Good Faith

Are you currently taking any medications, vitamins or supplements? If so, please list

Do you have any allergies to medication? If so, please list

Have you been on Isotretnoin(Accutane) in the last 6 months?

Yes
No

Are you pregnant or nursing?

Yes
No

Do you take any blood thinners (ex: Aspirin, Coumadin)

Yes
No

Do you have any medical problems or illnesses? If so, please explain

Do you smoke?

Yes
No

Do you drink alcohol

Yes
No

Do you get fever blisters?

Yes
No

Are you currently under the care of a Dermatologist?

Yes
No

Do you have facial implants?

Yes
No

Do you have a history of scarring easily?

Yes
No

Any allergy or sensitivity to:

Lidocaine
Benzocaine
Tetracaine
Latex
Food Allergies
Skin Allergies

Choose all that apply.

Do you have a history of the following?

Any disease that affects the muscles and nerves?

Yes
No

Amyotrophic Lateral Sclerosis (ALS)?

Yes
No

Myasthenia Gravis?

Yes
No

Eaton Lambert Disorder?

Yes
No

Bells Palsy?

Yes
No

Drooping eyelids?

Yes
No