EURO MED SPA
Phone 423.875.2225
CARING FOR THE TOTAL YOU
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Registration Forms                                                                        Download PDF
 
First Name:  Last Name: 
Birthdate:
Address:
City: State:
Zip:
 
 
Best phone number to contact you regarding your treatment and where we may leave a message:
 
Home Phone:
Cell Phone:
Work Phone:
E-mail:
How did you hear about us ?
Primary Care Physician:
PCP Phone Number
Emergency Contact and Phone number
 
 
This information is necessary for your procedure. Please answer yes or no to the following questions:
YES NO  
Are you using any prescribed medications ?
Are you using any Herbal medications?
Do you take oral anti-coagulant (blood thining) medications ?
Are you allergic to any cosmetic ingredients, medications or foods ?
Are you pregnant or trying to become pregnant?  
Do you use oral contraceptives?  
Do you use harmone replacement therapy?
Do you smoke? How much ? How long?
Do you spend a lot of time outdoors or use a tanning bed often ?
Do you have any tattoos or permanent makeup?
 
 
Please tell us your main concerns that brought you to our office today:
 
 
In addition to the above, please tell us which skin conditions concern you the most (Check all that apply) :
Sun Damage Brown spots
(Hyperpigmentation) 		White spots
(Hypopigmentation)
Uneven skin tone Visible exposed blood vessels Hard bumps under skin
Enlarged pores Clogged pores Blackheads / Whiteheads
Acne Excessive oiliness Pimples
Upper lip lines Wrinkless Scarring
Sun Spots Dry patches Unwanted Hair
Other    
What is your skin type: Dry Combination Oily Normal
How much water do you consume per day?
 
 
Please check the products you currently use and list the BRAND NAMES of Consmetic Products:
Cleanser Soap
Moisturizer Night Cream
Eye cream Astringent
Scrub Sunscreen
Vitamin A Creams Vitamin C Creams
Toner Glycolic Wash/Cleanser
Mask Salicylic Wash/Cleanser
Alpha Betahydroxy Cream
 
 
Are you using any topical creams, lotions or oral antibiotics for acne, skin cancer, anti-aging or hyperpigmentation?
Please list:
 
 
Have you ever had any of the following wrinkle fillers or implants:
Collagen Restylane Perlane Hylaform Juvaderm Silicone Radiesse
Sculptra     Other
* if so then when was it done ? What area ?
By whom?    
 
 
Please check any health problems, past or present:
Seizures Liver disease Skin cancer (type)
Hormonal Problems Diabetes Cystic Acne Thyroid
High Blood Pressure Heart Problems Collagen Lupus Sarcoidosis
Vasovagal Syncope PCOS Asthma Hepatitis
Autoimmune (lupus, schleroderma) Cancer Other
 
Do you have any of the following chronic skin disorders?
Psoriasis Dermatits Eczema Keloid Scarring
Fever Blisters Cold Sores Sun Blisters Herpes Simplex/Blisters
 
 
Have you ever undergone any of the following treatments?
Macrodermabrasion Acid Peel Cosmetic Surgery Lasers
Microdermabrasion Accutane Botox    
When and where was it done ?
 
Are you currently removing hair by any of the following methods ?
Waxing Tweezing "Nair" type products Electrolysis Laser Hair Removal
* if so when was it done What area ?
and what type of laser ?    
 
 
I certify that the above information is correct to the best of my knowledge.
Euro Med Spa Solutions Notes.
Dr Iqbal will be assisted by :
 
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