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Services
Products
Pricing
Blog
Contact

About Us
Services
Products
Pricing
Blog
Contact
Promotions
Patient Care
Free Consultation

About Us
Services
Products
Pricing
Blog
Contact
Promotions
Patient Care
Free Consultation

June Special: 10% off Dysport and Jeuveau Treatment

Patient Form

Patient Name*
First Last
Patient DOB*
MM slash DD slash YYYY
Gender Identify*
- Male
- Female
- Transgender male / Trans man / Female to male
- Transgender female / Trans woman / Male to female
- Genderqueer, neither exclusively male nor female
- Decline to specify
Preferred Pronoun*
- He
- She
- They
- We
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Can We Email You With Specials?*
How Were You Referred to Us?
Do You Currently Have A Primary Care Physician?
For What?
Are You Currently Under The Care of A Dermatologist (skin doctor)?
For What?
Do You Have or Have You Had Any of the Following Medical Conditions?
(Please check all that apply)
- Cancer
- Diabetes
- Diabetic neuropathy
- Neurological condition
- Numbness, tingling, nerve pain
- Seizure Disorder
- Active infection
- Skin disease/Skin Lesions
- Lupus
- Very fragile skin
- Vitiligo
- Psoriasis
- Abnormal wound healing
- Skin Cancer
- Herpes
- Cold sores
- Scleroderma or other collagen disorders
- Thyroid Imbalance
- Polycystic Ovarian Syndrome
- Blood clotting/bleeding abnormalities
- Circulation problems
- Irregular heartbeat
- Methomoglobinemia
- Pacemaker or defibrillator
- Permanent implant such as metal plate or screws
- Diastasis Recti
- Autoimmune Disease
- Liver Problems
- Hepatitis
- Kidney problems
- Past or present hernia
- HIV/AIDS
Please Explain
Please List Any Additional Conditions
Please List Any Surgeries with Dates
Have you ever had an allergic reaction/sensitivity to any of the following?
- Latex
- Aspirin
- Rubbing alcohol
- Propylene glycol
- Lidocaine/novocaine/tetracaine/benzocaine
- Hydroquinone or skin bleaching agents
- Topical Antibiotics
- Other (please explain)
Please Explain:*
Medications
List any RX medications, herbal supplements, and or vitamins you are presently taking or have taken in the last month:
Are you taking or have you taken any of the following in the past month?
- Aspirin
- Anti-inflammatory medication
- Birth Control Pills
- Antibiotics
- Blood thinning medication
Have you ever used Accutane?
When did you last use it?*
Have you ever used Gold Therapy?
When did you last use it?*
Have you ever had a Bone Marrow Transplant?
When?*
What topical antibiotics, medications or creams are you currently using or have you used in the past month?
- Retin A
- Alpha hydroxy
- Other (please specify)
Please specify*
History
Have you had light, laser, RF or treatment with another device, chemical peel, dermabrasion, or microdermabrasion to the affected area in last 6 months?
Details*
Have you had a facial surgery or cosmetic injections within the last year?
Have you used any of the following hair removal methods in the past 6 weeks?
- Shaving
- Waxing
- Electrolysis
- Plucking/Tweezing
- Stringing
- Depilatories
Have you had any sun exposure or use of any self-tanning lotions within last 2 weeks? (this includes indoor tanning)
Do you form keloid scars (significantly thick or raised)?
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) after physical trauma?
Describe*
Do you currently Smoke/Vape?
Do you have tattoos or piercings in the treatment area?
For Female Patients: Are you pregnant or trying to become pregnant?
For Female Patients: Are you breastfeeding?
I certify that the preceding medical, personal, and skin history statements are true and correct. A current medical history is essential for the caregiver to execute appropriate treatment procedures. I understand that the success of treatment depends largely on my cooperation with my treatment schedule and instructions/recommendations made by the staff. I agree to inform the staff that is treating me of any changes in my skin after treatment, as well as any changes in my overall health.*
- I agree to the above statement
Phone
This field is for validation purposes and should be left unchanged.

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Hours

Monday 8:00 a.m. – 6:00 p.m.

Tuesday, Thursday 8:00 a.m. – 1:30 p.m.

Wednesday 8:00 a.m. – 8:00 p.m.

Friday 8:00 a.m. – 4:30 p.m.

Saturday 8:00 a.m. – 2:00 p.m.

Sunday Closed

Contact us

1026 Union Road
Buffalo, NY 14224
716-712-1050
info@smg03.com

Copyright 2025 Southgate Medical Group.