New Patient Registration Form

Please correct the errors described below.

EMERGENCY CONTACT INFORMATION

EMPLOYMENT INFORMATION

GENERAL INFORMATION

I AM RESPONSIBLE FOR THIS ACCOUNT.

Skin Typing Matrix

Please answer the following questions by checking the number which best describes you. Your clinician will total your score during the consultation.

If your score is: (0-3) (4-7) (8-11) (12-15) (16-19) (20 - 24)

Additional skin response questions:

MEDICAL HISTORY

Your answers on this form will help us understand your medical concerns and conditions. If you are uncomfortable with any question, do not answer it. Best estimates are fine, if you cannot remember specific details

Medications:

Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs:

Add New Medications

Allergies or Reactions to Medications and Foods:

Add New Allergies

Health Maintenance

When were your most recent Screening tests:

Personal Medical History

Family History:

Social History: Tobacco Use

Add Family Member

Tobacco Use

Alcohol Use

Drug Use

Sexually Activity

CAFFEINE Intake

Weight

Diet

Diet, continued

Exercise

Socioeconomics

SPECIALTY HISTORY:

For women:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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