Medical Skin Care PERSONAL DEMOGRAPHICSDate of birth(Required) MM slash DD slash YYYY Name(Required) First Last How did you hear about us? Who referred you?(Required)Name / Google / Facebook / Instagram / Other MEDICAL SKIN HISTORYAre you currently under medical supervision?(Required) Yes No If YES, please explain(Required)Physician's NamePhone Number Are you under the care of a Dermatologist?(Required) Yes No Dermatologist's NamePhone NumberDate of Last Visit Are you currently using any medication orally or topically?(Required) Yes No If Yes, please specify below Have you ever used Accutane?(Required) Yes No If YES, When? Do any of these apply?(Required) None / Impossible! Pregnant Trying to become Pregnant Nursing ( check all that apply ) Do you have any Allergies or Sensitivities to anything?(Required) Yes No If YES, please explain Have you ever had a reaction to anything you have applied topically?(Required) Yes No If YES, please explain Do you have any physical injuries or disabilities that require special attention or care during your service?(Required) Yes No If YES, please explain SKIN HISTORY & GOALSHave you had any skin care treatments in the past?(Required) Yes No ( facials, peels, etc. )?If YES, Date of Last Visit?How often do you have Treatments?Specific skin concerns? What is your current skin care regime at home?(Required)(Please include types and brands of products.) In our treatment program it may be necessary for us to recommend changes for optimal results, is this okay?(Required) Yes No Do you usually breakout after a facial?(Required) Yes No Have you ever experienced unexplained itching, swelling, flaking, or redness after a facial??(Required) Yes No How long after cleansing do you notice oil or "shine" on your face?(Required) Does your skin generally feel tight or dry after cleansing?(Required) Yes No What type/brand of cosmetics and/or hair styling products do you use?(Required) How does your skin react to sun exposure?(Required) Always burns, never tans Usually burns Mildly burns, tans well Rarely burns, tans well Never burns, tans dark SPF Daily Use (Select all that apply)(Required) SPF 15 and lower SPF 15+ SPF 30+ It's in my moisturizer / foundation Re-apply throughout the day Eek! I don't use it regularly HELP US SERVE YOU BETTERWhat are you most interested in today? (select all)(Required) Relaxation/Pampering Deep Cleaning/Purification Renewed Appearance/Anti-aging Information/Maintain Skin Health Are you an information addict and have a "need to know" during your treatment? - or - Are you here to get a little peace & quiet and want to "leave it to the experts"?(Required) Need to Know Peace & Quiet If you are currently having or due for your menstrual period?(Required) Yes No If you have started any new medication(s)?(Required) Yes No If Yes, please specify new medications. Before Your Treatment: During your treatment light, safe exfoliating products will be used to improve the appearance of your skin. If you have Herpes Simplex Virus – type 1, please note exfoliating treatments may cause an outbreak. If you are sunburned, have visible cold sores or have any irritation, you may be asked to reschedule your appointment. After Your Treatment: Do not use 'active' products for a full 24 hours after your treatment. Avoid the sun and apply sunscreen as directed. If you have any questions or concerns, please schedule a complimentary follow-up appointment with your skin specialist within seven days. About Your Facial Treatment: Houston Medical Wellness Clinic skin care treatments are clinical treatments, and though some therapeutic massage may be included in your treatment, it is not a SPA treatment. You may experience flaking, sensitivity and/or light scabbing on extracted comedones, which is normal and will subside within a few days to reveal improved skin. I certify that the above information is true and correct. Legal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. Paper Copies You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies. Withdrawal of Consent You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically. My signature below means I understand the following. All of the information I have provided is true and to the best of my knowledge. Patient Signature(Required)CAPTCHA
