Patient Information and Medical History

For Botox/Dermal Filler Patients

Patients Name
Date of Birth
Age
Occupation
Place of Employment
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone - (###) - ### ####
Work Phone - (###) - ### ####
Cell Phone - (###) - ### ####
Email
Emergency Contact Name First Last
Emergency Contact Phone - (###) - ### ####
MEDICAL HISTORY
Are you currently under the care of a physician? Yes No
If Yes for what?
Are You currently under the care of a Dermatologist? Yes No
Do You have any of the Following medical Conditions? Cancer Diabetes High Blood Pressure Herpes Arthritis Frequent Cold Sores HIV/AIDS Keloid Scarring Skin Disease/ Skin Lesions Seizure Disorder Hepatitis Hormone Imbalance Thyroid Imbalance Blood Clotting Abnormalities Any Active Infection
Do you have any other Health Problems or Medical Conditions?
Please list all allergies
Have you ever had an allergic reaction to any of the following: Food Latex Aspirin Lidocaine Hydrocortisone Hydroquinone or skin bleaching agents Arnica Others
Please Check all that Apply
Please list any medications/supplements/Herbal Medications that you are taking.
Are you on any mood altering or Anti depression Medication? Yes No Third option
What Herbal Supplements do you use regularly?
Are You pregnant or Trying to get Pregnant? Yes No
Are you taking Birth Control mediation? Yes No
Have You ever had Botox Treatment? Yes No
Have You ever had Dysport Treatment? Yes No
Have you ever had Restylane/Juvederm Treatment? Yes No
Any Information you would like the doctor to know. Why you are here today?
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. First Last
Date / MM / DD YYYY

Patient Information and Medical History

Patient Information and Medical History

MEDICAL HISTORY