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Dr. Colvin
Shop
Patient Resources
New Patient Questionnaire
Home
Blog & Vlog
Procedures
Our Procedures
Injectables
Laser treatments
Medical Peels and Facials
CoolSculpting
Contact
Book Now
New Patient Form
By submitting this form online, you will save a significant amount of time during your visit.
Name
*
First Name
Last Name
Occupation
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home/Cell Phone
*
Marital Status
Single
Married
Other
Children?
Email
*
Date of Birth
*
MM
DD
YYYY
Age
*
How did you hear about Skin Medical Spa?
*
What is your ethnicity? (e.g Irish, Native American)
*
Past medical history - Please list (e.g hypertension, diabetes, other)
*
What medications are you currently taking?
*
Have you taken any other medications in the last 7 days?
*
Any allergies to medications, skin allergies? Y/N Explain:
*
Do you get cold sores, fever blisters or herpes outbreaks? Y/N If yes, how many per year?
*
Have you had any other cosmetic surgeries or procedures? Y/N If so, with whom?
*
Have you had Botox or Dysport before? Y/N If so, with whom?
*
Have you had filler before? Y/N If so, with whom?
*
Are you pregnant, trying to conceive or breastfeeding? Y/N or N/A
*
Skin Care Concerns
*
These are areas of concern for me: (check all that apply)
Body contouring/fat reduction
Fine Lines and Wrinkles
Crows Feet
Excess Hair
Sagging Skin
Laugh lines / Folds around mouth
Excess Underarm Sweating
Skincare
Age Spots / Freckles
Acne
Large Pores
Other
Are you vaccinated for COVID-19?
Yes
No
*All indicated fields must be completed.
Acknowledgement & Treatment Consent
*
I acknowledge that SKIN Medical Spa and Robert Colvin MD’s scope of medical treatment is limited to minor skin concerns and aesthetically oriented services. It is in no way a substitute or replacement for care by a dermatologist for healthcare concerns outside the scope defined above. I remain responsible for my own dermatologic medical care including but not limited to conditions such as skin cancer, melanoma, psoriasis, eczema, among others. I therefore hereby release SKIN Medical Spa and Dr. Robert Colvin and all of its employees or affiliates from all responsibility in connection with the diagnoses and treatment of such skin conditions. I authorize SKIN Medical Spa for treatment of cosmetic and minor skin care. I understand that I am financially responsible for services. I understand that if for any reason, treatment charges are contested, or social media(s) reviews are posted online, I give SKIN Medical Spa permission to discuss my treatment and history with third parties. I understand if I arrive late for my appointment, I may be required to reschedule my appointment to avoid disrupting the appointments of other clients. I understand that SKIN Medical Spa has a 48-hour cancellation policy. I also understand that if I fail to cancel or change my appointment outside of the specified 48- hour window, a charge will be applied.
Thank you!
