First Appointment FormIf you are already scheduled for an appointment, please fill out form below prior to coming in for your appointment to save some time. Thank you! 1) Date of Appointment:*2) First name:* 3) Last Name:* 4) Sex*MaleFemale5) Age:* 6) Date of Birth:* 7) Address:* Street AddressCityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState / Province / RegionPostal / Zip Code8) Phone Number:*Area Code-Phone Number9) May we leave a message on your phone?*YesNo10) E-mail:*11) Marital Status:*SingleMarriedSeparatedWidowed12) Primary Care Physician: 13) Emergency Contact:* 14) Emergency Contact Phone Number:* 15) Employer: 16) Occupation: 17) How did you hear about us?*YelpFacebookInstagramTwitterReferralothera. If referred, name of person: 18) The web is becoming a key way patients learn about our practice. Do you participate in any of the following? (check all that apply)*FacebookInstagramTwitterRealSelfGoogle+other/blogs19) Any websites that were helpful to use in researching our practice or the procedures?*YesNoNot Surea. If yes, please list: 20) Would you like to receive our MD Laser & Cosmetics Monthly Newsletter?*YesNoVia mail onlyVia email only21) Please check any of the following that pertain you:*Acne/PimplesBrown Aging SpotsCelluliteCrow's FeetFacial BlemishesFine LinesFrown LinesLove HandlesRed SpotsSpider VeinsSun Damaged SkinUneven Skin ToneUnsightly Leg VeinsUnwanted HairWeight LossWrinkles (facial)Bags Under EyesSmall lips/Lip Fillers22) What is your general medical history? 23) What is your main esthetic concern? 24) Any medications do take on a regular basis?* 25) Any known allergies?* 26) Do you have any medical conditions that we should know about?* 27) Have you ever had fever blisters (herpes)?*YesNoa. If yes, how often? 28) Have you ever been treated with antiviral medication?YesNo29) Do you currently have antiviral medication? If yes, which one?YesNo30) Are you pregnant or breastfeeding? * 31) Have you ever had implants, fillers or surgery done?*YesNo32) Have you ever had a facial? *YesNo33) Have you ever used any skin care products that addressed:a. Hyperpigmentation*YesNob. Acne*YesNoc. Dry skin*YesNo34) Are you presently using a vitamin “A” product?*YesNo35) Have you ever had a microdermabrasion treatment?*YesNo36) Have you ever seen a physician for above concerns?*YesNo37) Are you on any hormones? *YesNoa. If yes, which ones? SubmitClear All FieldsA copy of this submission will be automatically sent to your email. Thank you!Cancellation PolicyWe understand that unanticipated events happen occasionally in everyone’s life. In our desire to be effective and fair to all clients, the following policies are honored:If you need to cancel your appointment, please allow 24 hours to notify us of the cancellation. This allows the opportunity for someone else to schedule an appointment. If you are unable to give us 24 hours advance notice you will be charged a $50.00 cancellation fee for your appointment. This amount must be paid prior to your next scheduled appointment.