New Patient Form – W Aesthetics

W Aesthetics Registration Form

Please fill this form out completely before your visit. When you submit your information it comes to us securely. Thank you. If you need to fill out the information below in more than one session, please scroll to the bottom of the page and use the "Save and Continue Later" option.

Today's Date*
Date Format: MM slash DD slash YYYY
Primary Care Physician*
First Last
Patient Information
Patient Name*
First Middle Last
Former Name(s) if applicable
Marital Status*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Birth Date*
Date Format: MM slash DD slash YYYY
Age*
Gender*
How did you hear about W Aesthetics?
Home Phone*
Cell Phone*
Occupation*
Employer*
Employer Phone*
Are You Currently Under The Care of a Physician*
- Yes
- No
If yes, please list condition(s)
Health History
Have you ever been diagnosed or treated for:
Diabetes*
Keloids*
Thyroid Disease*
Cold Sores*
ALS*
Fainting*
Heart Murmur*
High Blood Pressure*
Bleeding Disorder*
Genital Herpes*
Eaton-Lambert*
Other Auto-Immune*
Phlebitis/DVT*
Acne (Accutane)*
HIV*
Hepatitis*
Myesthenia Gravis*
Smoking*
Corneal Abrasions*
Skin Cancer*
Eyelid Injury*
Blepharoplasty*
Tumors*
Circulatory Diseases*
Hyperpigmentation*
Migranes*
Contact Lenses*
Any Other Eye Issues*
Fitzpatrick Skin Type
Please choose the option that best describes your skin*
- I. Always burns, never tans, pale white skin
- II. Burns easily, tans minimally, white skin
- III. Burns moderately, tans uniformly, light brown skin
- IV. Burns minimally, tans well, olive skin
- V. Rarely burns, tans profusely, dark brown skin
- VI. Never burns, deeply pigmented, dark brown or black skin
Additional Information
Do you have any allergies?*
If "Yes", please list them here.
List all medications you are taking (Prescription and Over-the-Counter)
Have you used Accutane in the last 9 months?*
Are you using Retin-A, Tazarac, Triluma, or Renova?*
Are you pregnant or breastfeeding?*
What a scar appears is it significantly dark in color?*
Are you taking steroids (oral or injectable)?*
What is your natural eye color?*
What is your natural hair color?*
Previous Cosmetic Procedures
Acid Peel*
Botox, Dysport, Xeomin*
Collagen or HA fillers*
Laser Hair Reduction*
Lasers - Facial or Body (DOT, Fraxel, etc)*
Plastic Surgery*
Thread/Suture Lifts*
PRP*
Body Contouring*
Medical Grade Cosmetics*
Medical Grade Skin Care*
In Case of Emergency
Name of Local Friend or Relative*
First Last
Relationship to Patient*
Main Phone (Cell or Home)*
Work Phone*
Release
Name*
The above information is true to the best of my knowledge. I understand that I am financially responsible for any balance. I also authorize W Aesthetics to bill at the time of service. W Aesthetics may communicate with you through text, email, phone and/or post mail. By entering your name and date in the fields below you are accepting this form of correspondence.
First Last
Date*
Date Format: MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

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W Aesthetics Registration Form

Patient Information

Health History

Fitzpatrick Skin Type

Additional Information

Previous Cosmetic Procedures

In Case of Emergency

Release

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