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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
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Patient DOB
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Phone
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Address
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Street Address
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Can We Email You With Specials?
*
Please select
Yes
No
Are You Currently Under The Care of A Primary Care Physician?
Please Select
Yes
No
Are You Currently Under The Care of A Dermatologist (skin doctor)?
Please Select
Yes
No
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
Skin disease/Skin Lesions
Very fragile skin
Cold sores
Diastasis Recti
Active infection
Abnormal wound healing
Skin Cancer
Herpes
Thyroid Imbalance
Polycystic Ovarian Syndrome
Blood clotting/bleeding abnormalities
Circulation problems
Heart condition (specifically QT prolongation)
Methomoglobinemia
Pacemaker or defibrillator
Permanent implant such as metal plate or screws
Irregular heart beat
Lupus
Autoimmune Disease
Liver Problems
Hepatitis
Kidney problems
Past or present hernia
HIV/AIDS
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
PABA
Other (please explain)
Please Explain:
*
Medications
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
List any medications, herbal supplements, and or vitamins you are presently taking or have taken in the last month
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?
*
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?
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
Phone
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