Reveal forms3

Today's date (MM/DD/YYYY) __________________________ D.O.B (MM/DD/YYYY) ____________________________ Last name: ___________________________________________ First name: __________________________________ Address: _________________________________________________________________________________________ Home # __________________________ Work #____________________________ Cell #_______________________ Email address (will not be shared) ____________________________________________________________________ Occupation ____________________________________________________________________________________ In case of Emergency notify: ___________________________________#:__________________________________ Credit Card #: Type: ___________#: ______________________________________ Exp: (MM/YY)______/______ (Kept on file in case of missed appointment only - $25.00 missed appointment fee) May we contact you to remind you about upcoming or missed appointments? May we contact you regarding specials, new services, products and procedures? How did you hear about us? Referred By? ______________________________________________________________ What brings you in today? __________________________________________________________________________ PLEASE CHECK ANY PAST OR PRESENT MEDICAL CONDITIONS, TREATMENTS OR SITUATIONS THAT APPLY: Herpes simples, fever blister, cold sores Dark spots after pregnancy or skin injury Treatment with Accutane or any Anticoagulants Topical Medications or Creams (Retin-A, Obagi, Renova, etc) Cancer: Type/Location: ____________________________________________________________________________ Injuries or Surgeries? Please List ____________________________________________________________________ Do you take any medications, herbal or natural supplements on a daily basis? Yes / No If yes, please list ________________________________________________________________________________ Do you have any allergies to medications, foods, latex or any substances? If yes, please list ________________________________________________________________________________ What skincare products are you currently using? (Sunscreen, Cleanser, Moisturizer, Eye Cream, Scrub, Serums, Etc) ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ HELP US IDENTIFY BETTER TREATMENTS, PLEASE TELL US ABOUT YOUR SKIN… Sun Exposure in past 4-6 weeks (includes tanning beds, tanning/bronzing creams, spray tans) ADDITIONAL COMMENTS OR CONCERNS ABOUT YOUR SKIN OR OTHER? (E.g. rashes, birthmarks, wrinkles, age spots, etc) ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ PLEASE CIRCLE YOUR SKIN TYPE (FITZPATRICK SCALE) Tentative grouping
Skin Type
Classification
Skin Color
based on ethnicity &
skin complexion

Source: http://revealrejuv.ca/images/Client_Info_Form.pdf