Intake Forms

Intake Forms

Please complete the below Intake Form prior to your visit. Thank you for choosing us. We are looking forward to meeting you!

Internet
Visage Patient
Doctor
Insurance Company
Ad
Other
Search Engine (Google, Bing, Yahoo)
RealSelf
Yelp
Facebook
Twitter
Instagram
GooglePlus
LinkedIn
YouTube
Print Ads
Female
Male
Other
Yes
No
Yes
No
Spouse or Partner
Parent or Grandparent
Child or Grandchild
Sibling or Relative
Friend
Single
Married
Other
Never
Present: Occasional
Present: Daily
Past
Never
Present: Occasional
Present: Daily
Past
Never
Past
Present
Never
Present
Past
None
Allergic dermatitis or eczema
Rosacea
Melasma
Psoriasis
Seborrhoeic dermatitis
Cystic acne
Accutane use
Fever blisters or cold sores
Shingles
Skin cancer
Alopecia
None
Nasal allergy symptoms
Postnasal drainage
Difficulty breathing through nose
Sinus infections
Nose bleeds
Sleep apnea
Shortness of breath
Eye allergy symptoms
Dry eye symptoms
Glaucoma
Cataract
Corrective lenses
Vision correcting surgery
None
Chest pain
Heart attack
Stroke
High blood pressure
Deep vein clots
Irregular heartbeat
Pacemaker
Blood vessel stents
Replaced heart valves
None
Shortness of Breath
Bronchitis or emphysema
Asthma
None
Enlarged prostate
Kidney failure or dialysis
None
Frequent heartburn or reflux
Ulcer
Hepatitis
Inflammatory bowel disorder
None
Headache
Seizure disorder
Nerve disorder
Chronic pain disorder
Spine/disc disorder
Artificial joints
Insomnia
Treatment by psychiatrist
None
Diabetes
Anemia
Thyroid disorder
Autoimmune disorder
HIV/AIDS or exposure
Cancer (other than skin)
Current/upcoming pregnancy
Poor healing or scarring
Increased bleeding or bruising
Bad reaction to anesthetics
Significant weight fluctuation
None
Botox/fillers use
Chemical peel
Dermabrasion
Laser skin treatment
None
Alcoholism
Allergy (life-threatening)
Bad reaction to anesthetics
Bleeding tendencies
Cancer
Congenital defects
Diabetes
Epilepsy
Heart attacks
High blood pressure
Psychiatric illness
Stomach problems
Strokes
Suicide
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