Intake Form Fibroblast Plasma Skin Tightening Full Name * First Name Last Name Address * Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Phone Number * - Area Code Phone Number E-mail Date of Birth: health questions Does any of the following conditions relate to you? * Yes No Do you wear contact lenses? Is your skin oily? Are you menstruating? Do you tend to develop dark spots on skin from wounds or sun exposure? Do you scar easily from minor skin injuries? Do you bleed excessively from minor cuts? Do you have prosthetic implants? Have you had problems with healing from surgeries or permanent cosmetics in the past? Do you personally have any history or cancer? Are you currently undergoing radiation or chemotherapy treatment? Are you now or have ever been on an acne treatment or accutane? Are you currently taking antibiotics? Do you have any medical conditions that have resulted in a medical professional requiring you to premedicate with an antibiotic prior to a dental or other invasive procedure? Acne Medication Accutane in past 6 months Prescription Over-ยญยญthe-ยญยญcounter Supplements Antibiotics: Food Allergies Medication Allergies Latex Allergies Internal Metal Devices (Rods, Plates, Screws Joint Replacement Surgery (Hip, Knee, Elbows) Permanent Make--ยญup Tattoos Botoxยฎ Dermal Fillers (Juvedermยฎ, Restylaneยฎ, Radiesseยฎ, Sculptraยฎ) If you answered โYESโ to any questions above, use the space below to provide an explanation. Correlate your explanation to a specific question. A โYESโ answer does not indicate you are not an acceptable candidate for this cosmetic procedure. It may simply be information that is valuable to the practitioner/technician as each personโs body is unique. If you have any health conditions that affect healing, it is required you consult with a physician before proceeding. Please List All Non--โCosmetic Surgeries and Dates: Please List All Cosmetic Surgeries and Dates: fitzpatrick scale questionaire What is the color of your eyes? Light blue, Green - 0 Gray - 1 Blue -2 Dark Brown - 3 Brown/Black - 4 What is your natural hair color? Sandy Red - 0 Blonde - 1 Chestnut/Dark -2 Blonde Dark - 3 Brown Black - 4 What is the color of your skin? Reddish - 0 Very Pale - 1 Pale -2 Light Brown- 3 Dark Brown - 4 Do you have freckles? Many - 0 Several - 1 Few -2 Incidental - 3 None - 4 When was your last exposure to sun, lamps or cream? 0) More than 3 months 1) 2 to 3 months 2) 1 to 2 months 3) Less than 1 month 4) Less than 2 weeks Is your MOTHER of African American or East Indian descent (TECHNICIAN: add 10 points) YES NO Is your FATHER of African American or East Indian descent (TECHNICIAN add 10 points) YES NO If your heritage is Latin American, Asian-Pacific Islanders, Mediterranean, or native or indigenous to the America (TECHNICIAN: ADD 5 POINTS FOR YES) YES NO Upload photos of skin. Browse Files * Optional but HIGHLY advised. Cancel of Upload photos of your skin Browse Files Additional if you'd like! Cancel of summary for genetic disposition (FOR TECHNICIAN ONLY) SKIN TYPE SCORE (FOR TECHNICIAN ONLY) 0-8 I 9-16 II 17-24 III 25-30 IV 31-34 V 35 & OVER VI *Suntanned skin overrides the skin type score. Save Submit Should be Empty:
