No No No No Yes No Yes No Yes No Yes No Yes

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Received and completed by _____________________

PATIENT HEALTH INFORMATION First Name

Middle Initial

Last Name

Date of Birth -

ALLERGIES AND REACTIONS Allergy

Describe Reaction

Allergy

Decribe Reaction

Allergy

Describe Reaction

Allergy

Decribe Reaction

PURPOSE OF TODAY'S VISIT

HAVE YOU EVER HAD ANY OF THE FOLLOWING TREATMENTS?

□ □ □ □ □ □ □ □ □ □ □ □

Botox Filler Kybella IPL (Foto Facial) Microdermabrasion Chemical Peel Micro Needling Dermaplaning Laser Hair Removal Waxing DOT Laser (Fractional CO2) Cosmetic Surgery

When was your last treatment? When was your last treatment? When was your last treatment? When was your last treatment? When was your last treatment? When was your last treatment? When was your last treatment? When was your last treatment? When was your last treatment? What area? When was your last treatment? When?

When was your last treatment?

DO YOU TAKE OR USE ANY OF THE FOLLOWING?

□ Accutane How long have you been using this? □ Hydrocortisone How long have you been using this?

%

□ Retin A % How long have you been using this? □ Renova % How long have you been using this?

□ Retinol % How long have you been using this? □ Oral Antibiotics How long have you been using this?

HISTORY Do you wear sunscreen daily? □ Yes, Which brand? □ No Have you ever had skin cancer? □ Yes, What kind? □ No Do you have problems with scarring (keloid)? □ Yes □ No Are you currently pregnant? Are you trying to get pregnant? □ Yes □ No □ Yes □ No

RejuvMe, LLC

Do you use a tanning bed? □ Yes, Which brand? Have you ever had a cold sore? □ Yes, When was your last outbreak? Do you have problems with bleeding? □ Yes Are you currently breast-feeding? □ Yes

□ No □ No □ No □ No

Patient Initials ________________________

WHAT ARE YOUR SKIN CONCERNS? PLEASE CHECK ALL THAT APPLY

□ □ □

Fine lines and wrinkles Redness Sagging Skin

□ □ □

Deep lines and wrinkles Brown Spots Acne

□ □ □

Tone/Texture Facial Hair Other

ARE YOU INTERESTED IN MORE INFO ON ANY OF THESE SERVICES?

□ □ □

Fine lines and wrinkles Redness Sagging Skin

□ □ □

Deep lines and wrinkles Brown Spots Acne

□ □ □

Tone/Texture Facial Hair Other

WHAT SKINCARE PRODUCTS ARE YOU CURRENTLY USING?

SIGNATURE I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

Print name of Patient

Signature of Patient

Date

Print Name of Clinical Staff

Signature of Clinical Staff

Date

RejuvMe, LLC

Patient Initials ________________________