Name:_______________________________                  Date:______________________                Age:___________________

Reason for Today’s Visit: _________________________________________________________

 

MEDICAL HISTORY

Allergies:  ____________________________    Last Menstrual Period: ____________________   

Medications:  __________________________________________________________________

Pregnant or planning a pregnancy?  ○ Yes ○ No             Nursing?  ○Yes   ○No      

Form of Birth Control:  _______________   Surgeries:  _________________________________          

Primary Care Physician: _________________________________

 

FAMILY HISTORY    Has a blood relative ever had any of the following? (Please Circle)

Melanoma             Other Skin Cancer                Cystic Acne                        Psoriasis              Lupus               Rosacea                  Diabetes                                High blood pressure        Cancer                 Eczema

 

SOCIAL HISTORY

Occupation:  __________________________       Employer:  __________________________

Do you sunbathe or use tanning beds?  ○ Yes   ○ No       Frequent Sunburns?   ○ Yes  ○ No  

Do you wear daily sunscreen?    ○ Yes  ○ No    

Do you drink alcohol? ○ Yes ○ No              Do you smoke?  ○ Yes  ○ No

 

REVIEW OF SYSTEMS

Natural/Original Hair Color:   ○ Black  ○ Brown   ○ Light brown   ○ Blonde    ○ Red

Natural Eye Color:     ○ Brown   ○ Light brown   ○ Blue   ○ Green    ○ Hazel    ○ Gray

Skin Color:     ○ Very pale   ○ Fair   ○ Medium-olive   ○ Dark olive-brown    ○ Brown    ○ Black

Skin Cancer                      ○ Yes  ○ No        

Skin Biopsy                      ○ Yes  ○ No    

Slow wound healing      ○ Yes  ○ No    

Acne                                  ○ Yes  ○ No    

Itching                               ○ Yes  ○ No    

Eczema                              ○ Yes  ○ No    

Psoriasis                           ○ Yes  ○ No    

Nail Problems                  ○ Yes  ○ No    

Hair Loss                           ○ Yes  ○ No    

Sunburns                          ○ Yes  ○ No   

Rosacea                            ○ Yes  ○ No    

Excessive Scarring          ○ Yes  ○ No    

Keloids                              ○ Yes  ○ No    

Fungal Infections            ○ Yes  ○ No    

Seasonal Allergies          ○ Yes  ○ No    

Excessive Bleeding         ○ Yes  ○ No    

Cold Sores                         ○ Yes  ○ No    

 

 

 

 

Have you ever used or currently use the following products/medications for your skin?

Retin A                 ○ Yes  ○ No   Strength?  ___%

Accutane             ○ Yes  ○ No    

Antibiotics          ○ Yes  ○ No   Topical?       Oral? 

Metrogel             ○ Yes  ○ No    

Valtrex                 ○ Yes  ○ No    

Hydroquinone   ○ Yes  ○ No  

Levulan                ○ Yes  ○ No    

Zyclara/Aldara   ○ Yes  ○ No    

Effudex                ○ Yes  ○ No    

Latisse                  ○ Yes  ○ No    

 

Prior/current Dermatologist:  _______________________

 

 

Warts                                ○ Yes  ○ No    

HIV/AIDS                          ○ Yes  ○ No    

Hepatitis                           ○ Yes  ○ No

STD or STI                          ○ Yes  ○ No

Worrisome skin lesion  ○ Yes  ○ No    

Menopause                      ○ Yes  ○ No    

Artificial Heart Valve     ○ Yes  ○ No    

Joint Replacement         ○ Yes  ○ No    

Blood Clots                      ○ Yes  ○ No    

Diabetes                           ○ Yes  ○ No    

Thyroid Disorders           ○ Yes  ○ No    

Anxiety/Depression       ○ Yes  ○ No                     

Seizures                            ○ Yes  ○ No    

Muscle Weakness          ○ Yes  ○ No    

Joint Pain                         ○ Yes  ○ No    

Lupus                                ○ Yes  ○ No    

Abdominal Pain              ○ Yes  ○ No    

Weight Loss                     ○ Yes  ○ No

 

 

 

Have you ever had any the following?

Lasers Treatments          ○ Yes  ○ No    

Chemical Peels                ○ Yes  ○ No

Skin excision/cryogen   ○ Yes  ○ No    

Microdermabrasion       ○ Yes  ○ No    

Hydrafacial                      ○ Yes  ○ No    

Botox                                ○ Yes  ○ No                           

Collagen Fillers                ○ Yes  ○ No    

 

Current Skincare Products:  ______________________________________________________________________

___________________________________

 

 

 

COSMETIC QUESTIONNAIRE

 

Please circle any of the following  which  are concerns for you: 

 

Facial wrinkles

Birthmark

Acne

Scars

Rosacea

Lost volume in cheeks or face

Brown spots

Sun damage or precancerous areas

Unwanted hair on face or body

Blood vessels on face or legs

 

Please circle any of the following that you are interested in or would like to learn more about:

 

Botox

Laser hair removal

Laser treatment of facial redness

Laser treatment of leg veins

Sclerotherapy

Collagen fillers (Radiesse, Juvederm)

Laser skin resurfacing

Laser skin tightening

Chemical Peels

Acne Treatment

Skin Care Products/Regimen

 Patient Demographic Sheet

 

Name: ______________________________________

 

Date: _________________

Date of Birth: _________________                                                                                                     Marital Status: S M D W

Address: ___________________________________                                                                  City: ________________________

State: ______________________                                                                                                         Zip Code: _________________

Home Phone: ___________________                                                                                               Cell Phone: __________________

Employer: ________________________________________________________________

Email Address: __________________________________________________________

How did you hear about us? ___________________________________________ 

Policies and Procedures


Appointments

Please arrive 10 minutes prior to appointment time. Appointment confirmations are made via text
and email. Please provide a valid cell phone number and email address when scheduling
appointments.
Children are not allowed in treatment rooms due to the nature of services provided. Unattended
children are not allowed in the waiting room.
Cancellation Policy
Due to the individualized nature of services we offer, our service providers prepare treatment rooms
and services in advance for each client. If you are unable to keep an appointment, please let us know
at least 24 hours prior to your scheduled appointment. For appointments not cancelled within this
period, you will be charged a $35 fee. If you find that you are running more than 15 minutes late
for an appointment, we ask that you call and reschedule so that we may be on time for other
scheduled clients.

Pricing
The first visit Consultation Fee is $50. This applies to ALL new patients in order to establish with
Greater Mobile Laser & Aesthetic Center.
Pricing for additional services is determined by treatment type, the area to be treated, and the time
required per treatment area. Treatments are sold individually per session or in packages. All services
must be paid in full on the same day of treatment.
Payment Information
Cash, credit cards, checks, and Care Credit are accepted. There will be a $35 fee charged for all
returned checks. All payments are non-refundable.

I have read and understand the policies and procedures of Greater Mobile Laser & Aesthetic Center.
Signature: ________________________________________________ Date: ______________