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The Skin Center at Southgate Medical Group
Southgate Skin Care specializes in sublative rejuvenation, laser skin tightening, laser hair removal, microdermabrasion and chemical peels.
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Patient Form
Patient Name
*
First
Last
Patient DOB
*
MM slash DD slash YYYY
Gender Identify
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Male
Female
Transgender male / Trans man / Female to male
Transgender female / Trans woman / Male to female
Genderqueer, neither exclusively male nor female
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Preferred Pronoun
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He
She
They
We
Address
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Street Address
Address Line 2
City
Alabama
Alaska
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Maryland
Massachusetts
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New York
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Northern Mariana Islands
Ohio
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Email
*
Can We Email You With Specials?
*
Please select
Yes
No
How Were You Referred to Us?
Do You Currently Have A Primary Care Physician?
Please Select
Yes
No
For What?
Are You Currently Under The Care of A Dermatologist (skin doctor)?
Please Select
Yes
No
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?
Please Select
Yes
No
When did you last use it?
*
Have you ever used Gold Therapy?
Please Select
Yes
No
When did you last use it?
*
Have you ever had a Bone Marrow Transplant?
Please Select
Yes
No
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?
Please Select
Yes
No
Details
*
Have you had a facial surgery or cosmetic injections within the last year?
Please Select
Yes
No
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)
Please Select
Yes
No
Do you form keloid scars (significantly thick or raised)?
Please Select
Yes
No
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) after physical trauma?
Please Select
Yes
No
Describe
*
Do you currently Smoke/Vape?
Please Select
Yes
No
Do you have tattoos or piercings in the treatment area?
Please Select
Yes
No
For Female Patients: Are you pregnant or trying to become pregnant?
Please Select
Yes
No
For Female Patients: Are you breastfeeding?
Please Select
Yes
No
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
Email
This field is for validation purposes and should be left unchanged.
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