Skip to content
Menu
HOME
ABOUT
MEET THE PROFESSIONALS
FORMS
PATIENT REGISTRATION FORM
SUPPLEMENTAL HEALTH QUESTIONNAIRE
COVID-19 INFORMED CONSENT
PATIENT CONSENT FOR DERMAL FILLERS
CONSENT TO BOTULINUM TOXIN TREATMENT FOR FACIAL WRINKLES
CONSENT FOR AESTHETIC INJECTABLE TREATMENT (DEOXYCHOLIC ACID) INJECTION KYBELLA
PATIENT INFORMED CONSENT FORM FOR TREATMENT OF VASCULAR LESIONS
CONSENT FOR TREATMENT OF VASCULAR AND PIGMENTED LESIONS
CONSENT FOR LASER & LIGHT BASED HAIR REDUCTION
OUR CORONAVIRUS POLICY
COVID-19 NOTICE
COVID-19 PATIENT PROTOCOL
ABOUT THE PRACTICE
BLOG
PROCEDURES
INJECTABLES
– BOTOX
®
– JUVÉDERM VOLBELLA
– JUVÉDERM VOLLURE
– JUVÉDERM VOLUMA
– JUVÉDERM
®
ULTRA PLUS XC
– JUVEDERM® VOLUX® XC
– KYBELLA™
– JEUVEAU
®
– RESTYLANE
®
CONTOUR
– RESTALYNE
®
KYSSE
– RESTYLANE
®
LYFT
– RESTYLANE
®
REFYNE
– RESTYLANE
®
DEFYNE
– DYSPORT
®
LASER TREATMENTS
– LASER HAIR REMOVAL
– LASER GENESIS
– INTENSE PULSED LIGHT (IPL) THERAPY
BOTOX
®
THERAPIES
– BOTOX FOR MIGRAINES
– BOTOX FOR HYPERHIDROSIS
– BOTOX FOR TMJ
RVL PHARMACEUTICALS
– UPNEEQ
®
SKIN CARE
– CHEMICAL PEELS
– MICRONEEDLING
PRODUCTS
SKIN MEDICA
LATISSE
Buy products online!
REVIEWS
PATIENT RESOURCES
Why we recommend “face to face” consultations…
Before & After Galleries
Neurotoxins
Botox Before & After Photos
Crow’s Feet Before & After
Eyebrows Before & After
Glabellar Before & After
Lip Flip Before & After
Fillers
Chin Augmentation Before & After
Frown Lines Before & After
Jawline Fillers Before & After
Juvederm Before & After Pictures
Lip Fillers Before & After
Marionette Lines Before & After
Kybella
Kybella Before & After Pictures
Under Chin Fat Before & After
Laser Skincare
Laser Skin Rejuvenation Before & After
BOTOX
®
INFO »
BOTOX
®
FAQs
FAQs
PATIENT FORMS & INSTRUCTIONS
LASER TREATMENT CARE
GIFT CARDS
SPECIALS & EVENTS
Buy SkinMedica
®
Online!
BOTOX SPECIALS
DYSPORT SPECIALS
MONTHLY SPECIALS
ALLĒ LOYALTY PROGRAM
CONTACT
1805 E. Dyer Rd. #110, Santa Ana, CA 92705
Make an appointment
949.477.9740
SE HABLA ESPANOL
Search for:
Menu
HOME
ABOUT
MEET THE PROFESSIONALS
FORMS
PATIENT REGISTRATION FORM
SUPPLEMENTAL HEALTH QUESTIONNAIRE
COVID-19 INFORMED CONSENT
PATIENT CONSENT FOR DERMAL FILLERS
CONSENT TO BOTULINUM TOXIN TREATMENT FOR FACIAL WRINKLES
CONSENT FOR AESTHETIC INJECTABLE TREATMENT (DEOXYCHOLIC ACID) INJECTION KYBELLA
PATIENT INFORMED CONSENT FORM FOR TREATMENT OF VASCULAR LESIONS
CONSENT FOR TREATMENT OF VASCULAR AND PIGMENTED LESIONS
CONSENT FOR LASER & LIGHT BASED HAIR REDUCTION
OUR CORONAVIRUS POLICY
COVID-19 NOTICE
COVID-19 PATIENT PROTOCOL
ABOUT THE PRACTICE
BLOG
PROCEDURES
INJECTABLES
– BOTOX
®
– JUVÉDERM VOLBELLA
– JUVÉDERM VOLLURE
– JUVÉDERM VOLUMA
– JUVÉDERM
®
ULTRA PLUS XC
– JUVEDERM® VOLUX® XC
– KYBELLA™
– JEUVEAU
®
– RESTYLANE
®
CONTOUR
– RESTALYNE
®
KYSSE
– RESTYLANE
®
LYFT
– RESTYLANE
®
REFYNE
– RESTYLANE
®
DEFYNE
– DYSPORT
®
LASER TREATMENTS
– LASER HAIR REMOVAL
– LASER GENESIS
– INTENSE PULSED LIGHT (IPL) THERAPY
BOTOX
®
THERAPIES
– BOTOX FOR MIGRAINES
– BOTOX FOR HYPERHIDROSIS
– BOTOX FOR TMJ
RVL PHARMACEUTICALS
– UPNEEQ
®
SKIN CARE
– CHEMICAL PEELS
– MICRONEEDLING
PRODUCTS
SKIN MEDICA
LATISSE
Buy products online!
REVIEWS
PATIENT RESOURCES
Why we recommend “face to face” consultations…
Before & After Galleries
Neurotoxins
Botox Before & After Photos
Crow’s Feet Before & After
Eyebrows Before & After
Glabellar Before & After
Lip Flip Before & After
Fillers
Chin Augmentation Before & After
Frown Lines Before & After
Jawline Fillers Before & After
Juvederm Before & After Pictures
Lip Fillers Before & After
Marionette Lines Before & After
Kybella
Kybella Before & After Pictures
Under Chin Fat Before & After
Laser Skincare
Laser Skin Rejuvenation Before & After
BOTOX
®
INFO »
BOTOX
®
FAQs
FAQs
PATIENT FORMS & INSTRUCTIONS
LASER TREATMENT CARE
GIFT CARDS
SPECIALS & EVENTS
Buy SkinMedica
®
Online!
BOTOX SPECIALS
DYSPORT SPECIALS
MONTHLY SPECIALS
ALLĒ LOYALTY PROGRAM
CONTACT
Search for:
HOME
ABOUT
MEET THE PROFESSIONALS
FORMS
PATIENT REGISTRATION FORM
SUPPLEMENTAL HEALTH QUESTIONNAIRE
COVID-19 INFORMED CONSENT
PATIENT CONSENT FOR DERMAL FILLERS
CONSENT TO BOTULINUM TOXIN TREATMENT FOR FACIAL WRINKLES
CONSENT FOR AESTHETIC INJECTABLE TREATMENT (DEOXYCHOLIC ACID) INJECTION KYBELLA
PATIENT INFORMED CONSENT FORM FOR TREATMENT OF VASCULAR LESIONS
CONSENT FOR TREATMENT OF VASCULAR AND PIGMENTED LESIONS
CONSENT FOR LASER & LIGHT BASED HAIR REDUCTION
OUR CORONAVIRUS POLICY
COVID-19 NOTICE
COVID-19 PATIENT PROTOCOL
ABOUT THE PRACTICE
BLOG
PROCEDURES
INJECTABLES
– BOTOX
®
– JUVÉDERM VOLBELLA
– JUVÉDERM VOLLURE
– JUVÉDERM VOLUMA
– JUVÉDERM
®
ULTRA PLUS XC
– JUVEDERM® VOLUX® XC
– KYBELLA™
– JEUVEAU
®
– RESTYLANE
®
CONTOUR
– RESTALYNE
®
KYSSE
– RESTYLANE
®
LYFT
– RESTYLANE
®
REFYNE
– RESTYLANE
®
DEFYNE
– DYSPORT
®
[Column]
LASER TREATMENTS
– LASER HAIR REMOVAL
– LASER GENESIS
– INTENSE PULSED LIGHT (IPL) THERAPY
BOTOX
®
THERAPIES
– BOTOX FOR MIGRAINES
– BOTOX FOR HYPERHIDROSIS
– BOTOX FOR TMJ
RVL PHARMACEUTICALS
– UPNEEQ
®
SKIN CARE
– CHEMICAL PEELS
– MICRONEEDLING
PRODUCTS
SKIN MEDICA
LATISSE
Buy products online!
REVIEWS
PATIENT RESOURCES
Why we recommend “face to face” consultations…
Before & After Galleries
Neurotoxins
Botox Before & After Photos
Crow’s Feet Before & After
Eyebrows Before & After
Glabellar Before & After
Lip Flip Before & After
Fillers
Chin Augmentation Before & After
Frown Lines Before & After
Jawline Fillers Before & After
Juvederm Before & After Pictures
Lip Fillers Before & After
Marionette Lines Before & After
Kybella
Kybella Before & After Pictures
Under Chin Fat Before & After
Laser Skincare
Laser Skin Rejuvenation Before & After
BOTOX
®
INFO »
BOTOX
®
FAQs
FAQs
PATIENT FORMS & INSTRUCTIONS
LASER TREATMENT CARE
GIFT CARDS
SPECIALS & EVENTS
Buy SkinMedica
®
Online!
BOTOX SPECIALS
DYSPORT SPECIALS
MONTHLY SPECIALS
ALLĒ LOYALTY PROGRAM
CONTACT
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM
Aesthetics Staff
2020-06-22T15:20:29-07:00
Patient Name
*
First
Last
Patient Email
*
Patient Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Date of signup
MM slash DD slash YYYY
I want to receive promotions and email communications
Yes
Patient Occupation
*
Patient Phone
*
This phone is my
Cell
Home
Office
Patient Date of Birth
*
MM slash DD slash YYYY
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?
MM slash DD slash YYYY
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
Δ
icon-angle
icon-bars
icon-times
Sign up for Newsletter