DMK Consultation Form

Client Details

Name*

First Last

Address*

Street/PO Box Address Line 2 City State ZIP Code

Phone

Email

Occupation

Ethnicity*

Referred By*

Skin

Check the areas you would like to improve with your skin*

List skin care products currently using

Have they achieved the results you want?*

No
Yes

Do you use sunscreen daily?*

No
Yes

Body

Check the areas you would like more information on or are interested in*

List the body care products you are currently using

Have they achieved the results you want?*

No
Yes

Medical History

Do you smoke?*

No
Yes

Have you in the past or present or had any of the following problems?*

If other, please explain.

Have you had plastic surgery?*

No
Yes

If yes, please give description, date, and Surgeon's name.

Are you currently using Retin-A, Retinol, AHA, or any peeling agent?*

No
Yes

If yes, how long? Strength? And results?

Do you suffer from claustrophobia or anxiety?*

No
Yes

Any known allergies to: Cosmetics, Food, Medication, Animals, Pollens, or Metals?*

Do you have a tendency to keloid scar?*

No
Yes

Have you had a skin peel in the past 2 years?*

No
Yes

If yes, results and brand.

Medication

Have you been under a physicians care during the past 3 years?*

No
Yes

Are you currently taking any medication?*

No
Yes

If yes, name of medication and how long?

Are you currently taking accutane or roaccutane?*

No
Yes

If yes, how long?

Dietary or Herbal Supplements or Vitamins?*

No
Yes

If yes, name of medication and how long?

How much water do you drink daily? (# of glasses)*

Client Signature

First Last

Date

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