Hair loss checklist. 1. Hair loss patient history from received and completed
|
|
|
- Lenard Gordon
- 5 years ago
- Views:
Transcription
1 Hair loss checklist 1. Hair loss patient history from received and completed 2. Complete the attached medical release form: include all doctors that have checked lab work, performed biopsy or evaluated hair loss. If you do not want to complete the request, you can bring with you recent (last 6 months) blood work, any prior (scalp) biopsy report or doctors notes to the visit. If you do not have any of these, anticipate lab work and/or a biopsy at DTLA Derm. 3. Picture of your hair when it was not thinning. 4. Do not shampoo hair for 1-2 days before your visit. 5. Do not comb or brush your hair the morning of your visit. 6. Do not wear nail polish. 7. Do not bring a bag of hair. We will examine and pluck hair during your visit. 8. We take hair loss very seriously due to the large impact it has on a patient s quality of life. We, therefore, devote a special time during the week for patients with this problem enabling more time, attention and detail to be given for this condition. As part of this, you need to be prepared for your visit. Your visit will only be focused on this condition. Hair loss appointments will not include skin checks, acne evaluation, cosmetics, etc.
2 Rachael Cayce, MD/ Elizabeth Gutmark, MD/ Katrina Spaunhurst, MD/ Joanna Chan, MD 1127 Wilshire Blvd, Suite 909 Los Angeles, CA Phone: (213) Fax: (213) AUTHORIZATION TO RECEIVE OR RELEASE HEALTHCARE INFORMATION Patient s Name: Date of Birth: Parent/Legal guardian name: Authorization to receive: I authorize records to be sent to DTLA DERM from: 1. Name: Tel: Fax: 2. Name: Tel: Fax: 3. Name: Tel: Fax: Authorization to release: I authorize DTLA Derm to release records to: 1. Name: Tel: Fax: 2. Name: Tel: Fax: Myself: 0_ Name: I would like an electronic copy of my record. I would like a copy mailed to me of my record. I understand there is a $.25 fee per page plus a $10 clerical fee in compliance with the California law. I would like the following sent (check all that apply) Visit notes, including treatment, prescriptions, diagnoses Labs (blood work) and Pathology results from biopsies, excisions All health-related information Dates: From: / / To: / / Patient Signature: Date: Parent/ Legal Guardian Signature: Date:
3 Hair Loss/Hair thinning/alopecia Patient History Form We take hair loss very seriously due to the large impact it has on a patients quality of life. We therefore devote a special time during the week for patients with this problem where more time, attention and detail can be given for this condition. As part of this, you need to be prepared for your visit. Your visit will only be focused on this condition. Hair loss appointments will not include skin checks, acne evaluation, cosmetics, etc. ONSET 1. How long ago did the hair loss start? 2. Did it happen rapidly overnight? YES OR NO 3. Who noticed the hair shedding/hair loss? 4. Was your hair gray all of a sudden in a particular area? YES OR NO 5. Which family members have had hair problems (CIRCLE ALL THAT APPLY) a. Mom/Dad b. Siblings c. Children d. Grandparents 6. Is this the first and only time you have experienced hair loss? YES OR NO a. Is it different from the other time you experienced hair loss? Please explain.
4 SYMPTOMS 7. Is the hair shedding (you can see the hair bulb) or is it breaking? 8. Does your hair have a dry texture? YES OR NO 9. Is your scalp? a. Flaking YES OR NO b. Itching YES OR NO c. Painful or tender YES OR NO d. Sensitive or irritated YES OR NO e. Greasy YES OR NO f. Red (assessed in the mirror or what other people say) YES OR NO 10. Does your scalp have a funny odor sometimes? YES OR NO 11. Do you dye your hair? YES OR NO 12. Do you have any divots/impressions/dots or ridges on your nails? YES OR NO 13. Where do you see hair? a. Home b. Shower c. Other: 14. How many hairs do you estimate you are losing at a time? a. 100 YES OR NO b. >100 YES OR NO c. I don t know, but the hair is in clumps YES OR NO 15. Where have you noticed hair loss (CIRCLE ALL THAT APPLY)? a. Top/front of scalp b. Sides of scalp c. Back of scalp d. Armpits e. Groin f. Eyebrows g. Legs h. Eyelashes
5 16. Draw on the diagram where the hair loss is the most? 17. Women, do you have hair growth on your? a. Chin/thick sideburns YES OR NO b. Chest/nipples YES OR NO c. Area below your belly button YES OR NO TREATMENTS 18. What resources have you used to learn about hair loss? a. Internet YES OR NO b. Friends YES OR NO c. Any questions or concerns you have based on your research 19. Have you seen another doctor for this problem? YES OR NO a. If yes, was lab testing performed? YES OR NO This must be brought to your visit or sent before your visit b. If yes, was a biopsy performed? YES OR NO This must be brought to your visit or sent before your visit 20. Are you using Rogaine/Minoxidil? YES OR NO a. Strength (2 or 5%) b. How often (once or twice a day) c. Are you consistent with use? YES OR NO d. How long have you used it? e. Did it work? YES OR NO f. Did it cause more hair to fall out in the beginning? YES OR NO
6 g. Any side effects? 21. Are you using anything else to treat your hair loss? a. Biotin YES OR NO dose: b. Spironolactone/aldactone (dose) YES OR NO dose: c. Shampoo/conditioner system like viviscal YES OR NO d. Finasteride/Propecia YES OR NO dose: e. Dutasteride YES OR NO f. LED light helmets YES OR NO g. Ketoconazole shampoo YES OR NO h. Prednisone YES OR NO dose: i. Antibiotics (doxycycline, clindamycin, benzoyl peroxide) YES OR NO list: j. Prior steroid injections YES OR NO k. Iron supplements (dose) YES OR NO dose: l. Other vitamins (list:) 22. Any side effects from treatments( i.e scalp irritation, dizziness, hair growth in unwanted areas, breast enlargement, etc) 23. Has any treatment helped more than others (explain)? 24. What goals or expectations do you have for treatment? SOCIAL IMPACT 25. What is your occupation? 26. How severely has it affected your life? 27. Are you fearful of becoming bald?
7 DERMATOLOGY LIFE QUALITY INDEX (adapted) this screening will be repeated at future visits Name: Date: Score: The aim of this questionnaire is to measure how much your hair loss has affected your life OVER THE LAST WEEK. Please tick one box for each question. 1. Over the last week, how itchy, sore, Very much painful or stinging has your scalp A lot been? A little Not at all 2. Over the last week, how embarrassed Very much or self conscious have you been because A lot of your hair loss? A little Not at all 3. Over the last week, how much has your Very much hair loss interfered with you going A lot shopping or looking after your home? A little Not at all Not relevant 4. Over the last week, how much has your Very much hair loss influenced the clothes A lot you wear like hats? A little Not at all Not relevant 5. Over the last week, how much has your Very much hair loss affected any social or A lot leisure activities? A little Not at all Not relevant 6. Over the last week, how much has your Very much hair loss made it difficult for A lot you to do any sport? A little Not at all Not relevant
8 7. Over the last week, has your hair loss prevented Yes you from working or studying? No Not relevant If "No", over the last week how much has A lot your hair loss been a problem at A little work or studying? Not at all 8. Over the last week, how much has your Very much hair loss created problems with your A lot partner or any of your close friends A little or relatives? Not at all Not relevant 9. Over the last week, how much has your Very much hair loss caused any sexual A lot difficulties? A little Not at all Not relevant 10. Over the last week, how much of a Very much problem has the treatment for your A lot hair loss been, for example by making A little your home messy, or by taking up time? Not at all Not relevant Please check you have answered EVERY question. Thank you. AY Finlay, GK Khan, April this must not be copied without the permission of the authors.
9 Check the box(es) if you are experiencing any of the following: Problem with bleeding Excessive fatigue Dry eyes Unintentional weight loss or gain Staphylococcal infections Problems with scarring (hypertrophic or keloid) Artificial heart valve Artificial joints placed within the past two years Blood thinners (aspirin, warfarin) Defibrillator Allergy to lidocaine/anesthetics Allergy to topical antibiotic (Neosporin) Problems with healing Joint or back aches Change in vision or blurry vision Abdominal pain Migraines Irregular menses/periods Dry mouth Hair loss Rash with use of adhesive bandages Currently pregnant or planning a pregnancy Leg swelling Muscle Weakness Past Medical History (Please circle all that apply) Anxiety Asthma Hay Fever/Allergies Depression Diabetes Kidney Disease Liver disease HIV/AIDS Thyroid Problems Leukemia Lymphoma Radiation Treatment Sjogren s syndrome Lupus Past Surgical History: (please circle all that apply) Mechanical Heart Valve Replacement Biological Heart Valve Replacement
10 Joint Replacement within last 2 years Bone Marrow Transplantation Organ Transplantation Skin Disease History: (please circle all that apply) Acne Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Sun sensitivity Psoriasis Family History: Eczema: siblings /mother / father / child / grandparents Psoriasis: siblings /mother / father / child / grandparents Medications: Please all medications you take from other doctors and length of therapy
Hair Loss/Hair thinning/alopecia Patient History Form
Hair Loss/Hair thinning/alopecia Patient History Form We take hair loss very seriously due to the large impact it has on a patients quality of life. We therefore devote an alopecia clinic appointment for
Patient Information. M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Whom may we thank for referring you?
Today's : First Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Patient Information Last Name Email: Primary Care Physican:
CLIENT QUESTIONNAIRE TODAY S DATE: SPECIFIC CONCERNS REGARDING YOUR SKIN (CHECK ALL THAT APPLY) I AM INTERESTED PRIMARILY IN:
CLIENT QUESTIONNAIRE TODAY S DATE: NAME: DATE OF BIRTH: SPECIFIC CONCERNS REGARDING YOUR SKIN (CHECK ALL THAT APPLY) Fine Lines/Wrinkles Dark Circles Puffy Eyes Blotchiness/Discoloration Uneven Skin Tone
HEALTH HISTORY INFORMATION
HEALTH HISTORY INFORMATION Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: Female Male Home Phone: Cell Phone: Leave messages at: Home Cell Other: Email address:
COLORADO AESTHETIC CENTER
COLORADO AESTHETIC CENTER 9320 Grand Cordera Parkway, Suite #250 Colorado Springs, CO 719.387.7800 Skin and Health Questionnaire Please answer the following questions thoroughly, as this provides a better
Welcome to Medspa 1064, Connecticut s Premier Center for Cosmetic Laser Medicine
MedSpa 1064 Suites at Somerset Square 140 Glastonbury Blvd. Glastonbury, CT 06033 860.657.1064 Welcome to Medspa 1064, Connecticut s Premier Center for Cosmetic Laser Medicine This form is to introduce
Brilliant Bodywork. Name: Date: Address: City: State: Zip: Home Phone: Business Phone: Cell Phone: Date of Birth: address:
Brilliant Bodywork Skin Care History Questionnaire and Waiver Please answer the following questions so that your Skin Care Specialist may have a better understanding of your general health and lifestyle,
The hair follicle is preserved. Therefore, hair regrowth is always possible.
WHAT ARE THE DIFFERENT TYPES OF HAIR THINNING? NON-SCARRING types of hair thinning are due to changes in your hair cycle, hair follicle size, hair breakage, or a combination of these changes. The hair
Informed Consent For Facial Rejuvenation/Collagen Remodel
Informed Consent For Facial Rejuvenation/Collagen Remodel Client s name: Date: I authorize SilkySkin Laser Centers to perform the laser procedure. You will be treated with the Cynosure Elite TM laser,
CLEAR TOE INTAKE INFORMATION
CLEAR TOE INTAKE INFORMATION Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: Female Male Home Phone: Cell Phone: Leave messages at: Home Cell Other: Email address:
COLORADO DERMATOLOGY SPECIALISTS HAIR LOSS QUESTIONNAIRE
COLORADO DERMATOLOGY SPECIALISTS Poplar: Denver: 3540 S. Poplar St, Suite 300 1960 N. Ogden St Suite 555 Denver, CO 80237 Denver, CO 80218 303 850 9715 303 831 0400 HAIR LOSS QUESTIONNAIRE Name: Date:
PACKAGE LEAFLET: INFORMATION FOR THE USER. Clindamycin 300 mg Capsules Clindamycin (as hydrochloride)
PACKAGE LEAFLET: INFORMATION FOR THE USER Clindamycin 300 mg Capsules Clindamycin (as hydrochloride) Read all of this leaflet carefully before you start taking this medicine because it contains important
Imbue Aesthetics & Wellness PATIENT REGISTRATION FORM
Today's Date Legal Name Marital Status Sex DOB Age Mailing Address Preferred Phone Number Email Do we have your permission to add you to our email list to receive newsletters and promotions? YES NO Emergency
East Hill Medical Group
Name: of Birth: Address: City: State: Zip: Home Tel. #: Cell #: Employer: Occupation: Emergency Contact: Relationship: Phone: Email: How Referred: Parents Ethnic Background: Previous Treatments Year: Area(s):
please complete the following:
Page 1 of 7 PLEASE NOTE: 1. All sections of this form must be CLEARLY PRINTED in detail to prevent delays. The inability to read the report will result in delays. 2. Please attach clear photos of the affected
How did you hear of us? Friend: Our patient: Magazine: Physician referral:
Patient Information Today s Date: Title: Dr. Mr. Mrs. Ms. Name (Last, First, Middle) Gender: M F Age: Birthdate: Social Security: Street Address City, State & ZIP Home Phone Cell Phone Work Phone Email
Consultation Form: Coffeeberry Peel
Consultation Form: Coffeeberry Peel NAME: ADDRESS: TELEPHONE NUMBER: DATE OF BIRTH: EMERGENCY CONTACT: EMAIL ADDRESS: OCCUPATION: DOCTORS NAME/SURGERY: We aim to ensure clients have the best possible advice
Massey Medical. Medical History (Dermal Filler) MEDICAL INFORMATION: I am interested in the following services: Juvederm: Botox:
Medical History (Dermal Filler) Name: Date: _ Date of Birth: Phone: _ MEDICAL INFORMATION: I am interested in the following services: Juvederm: Botox: NO YES Allergies history of severe allergy or anaphylaxis.
Client Questionnaire Skin & Health
Client Questionnaire Skin & Health Please answer the following questions thoroughly and completely, as this provides a better understanding of your general health, lifestyle and skin care concerns; thereby
Brow and Beauty Bar - Permanent Makeup
General Consent and Procedure Permit Clients Full Name Mr/Mrs/Miss/Ms Address e-mail I hereby authorize Erin Exline to perform upon myself permanent cosmetic enhancement. If any unforeseen condition arises
FACT SHEET: ISOTRETINOIN INFORMATION FOR PATIENTS
FACT SHEET: ISOTRETINOIN INFORMATION FOR PATIENTS You have been prescribed isotretinoin (=Roaccutane, Oratane) for your acne. It is used for acne which does not respond to other treatments, scarring and
Consultation Form: AHA Chemical Peel
Consultation Form: AHA Chemical Peel NAME: ADDRESS: TELEPHONE NUMBER: DATE OF BIRTH: EMERGENCY CONTACT: EMAIL ADDRESS: OCCUPATION: DOCTORS NAME/SURGERY: We aim to ensure clients have the best possible
Contact Information. Idaho Falls. Idaho Falls, ID (208) (307) NAME. City / state / zip
Contact Information NAME physical street address City / state / zip Home phone cell phone email address want monthly specials? date of birth Age gender Male female How did you hear about us? WHICH AREAS
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM PATIENT DATA DATE: Last First MI: Date of Birth: Social Security #: Gender: Female Male Marital Status: PHONE Home: Preferred Home Work Cell Work: Is it okay to leave a detailed
while safe accutane breastfeeding pores on accutane large causes d vitamin anemia deficiency reversal accutane
Effects pregnancy accutane after, on skin accutane while care tips, skin for on dry accutane best moisturizer, problems accutane does cause liver. Does shrink pores accutane permanently, accutane work
Client Intake Form. Name: Date: Address: City: ST: Zip: Phone:
Client Intake Form Name: Date: Last First Address: City: ST: Zip: Email: Phone: How did you hear about Skin Renew Day Spa? What are your main concerns? How long have you been experiencing your current
DOES ACCUTANE CAUSE LIVER PROBLEMS
DOES ACCUTANE CAUSE LIVER PROBLEMS Does Accutane Cause Liver Problems Skin care whilst on accutane Taking prednisone with accutane How to clear up acne without accutane Accutane 10 mg bid po angielsku
Patient Information Leaflet. Dermal Filler
Patient Information Leaflet Dermal Filler When considering treatment with dermal fillers we want you to have a safe treatment. Some risks are unavoidable and out of your control. The following information
Intake Form Chemical Peels, Microdermabrasion, and Facials
Intake Form Chemical Peels, Microdermabrasion, and Facials Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: 0 Female 0 Male Home Phone: Cell Phone: Leave messages
Client Information Sheet
Esthetic Laser Clinic 8381 Old Courthouse Road Suite 300 Vienna, VA 22182 (703) 288 0085 www.elaserclinic.com Client Information Sheet Last Name First Name: Address City State Zip Code D.O.B. (MM/DD/YY)
CASA Jan 20/June 16 Meeting Questions for Dr. Donovan
CASA Jan 20/June 16 Meeting Questions for Dr. Donovan *CA = Cicatricial Alopecia, CCCA=Central Centrifugal Cicatricial Alopecia, FFA=Frontal Fibrosing Alopecia GENERAL DR. RESPONSES 1. Is scarring alopecia
Personal Profile and Health History
--CAPITAL AESTHETICS Personal Profile and Health History Name: Home Phone: Address: Work Phone: City/State/Zip: Date of Birth: Age: Gender: M F Occupation: Email address: How did you hear about us? What
SKIN CARE DURING CHEMOTHERAPY
SKIN CARE DURING CHEMOTHERAPY What you need to know to safely take care of your skin during treatment 2 Why is good skin care important during chemotherapy? Your skin is one of the areas of your body that
WOMEN'S Regaine EXTRA STRENGTH
WOMEN'S Regaine EXTRA STRENGTH MINOXIDIL 5% W/W TOPICAL FOAM Consumer Medicine Information Please read this booklet carefully. It will help you understand how to use Foam and what to expect from its use.
Informed Consent for Light Energy Tattoo Removal
Dr. Joseph G. Protain 813 Kentwood Dr. Boardman, OH 44512 (330)953-3515 Informed Consent for Light Energy Tattoo Removal Customer s name: Date: I, consent to and authorize and members of his/her staff
513 Maple Ave West, Vienna, VA
CLIENT INFORMATION AND CONSENT FORM: SKIN CARE Name Date of Consultation Address City State Zip Home phone ( ) Cellular phone ( ) E-mail Date of birth Emergency contact and telephone number How did you
CLIENT QUESTIONNAIRE
CLIENT QUESTIONNAIRE YOUR INFORMATION Name Age DOB Address City State Zip Home Phone Cell Phone Email MEDICATIONS Medication When How Long Medication When How Long Antibiotics Androstendione Accutane Testosterone
ACCUTANE SKIN RASH HANDS
ACCUTANE SKIN RASH HANDS Accutane Skin Rash Hands Accutane of doses small Accutane drink can i on wine while Accutane and irritable bowel disease Accutane itchy ears and Depression effect tests newsletter
Psoralen Tablets (Methoxypsoralen)
Psoralen Tablets (Methoxypsoralen) Psoralen (Methoxypsoralen) Tablets This information is intended to provide you with information about your treatment and should be read thoroughly so that you are aware
Medication Name Reason Taken Dosage Last Date Taken
CLIENT HISTORY FORM Print Name Location of Service: Email Birth Date Age Gender @ Female Address City State / Male Emergency Contact Name and Number Home Phone ( ) Cell Phone ( ) Today s Procedure Description:
GENERAL CONSENT AND PROCEDURE PERMIT FORM
GENERAL CONSENT AND PROCEDURE PERMIT FORM Please read this form fully and sign at the end. If you are unsure about a particular detail of the form, please speak to your therapist. If unforeseen condition
CLIENT QUESTIONNAIRE
CLIENT QUESTIONNAIRE YOUR INFORMATION Name Age DOB Address City State Zip Home Phone Cell Phone Email MEDICATIONS Medication When How Long Medication When How Long Antibiotics Androstendione Accutane Testosterone
READ THIS FOR SAFE AND EFFECTIVE USE OF YOUR MEDICINE PATIENT MEDICATION INFORMATION. TRAVATAN Z Travoprost Ophthalmic Solution
READ THIS FOR SAFE AND EFFECTIVE USE OF YOUR MEDICINE PATIENT MEDICATION INFORMATION Pr TRAVATAN Z Travoprost Ophthalmic Solution Read this carefully before you start taking TRAVATAN Z and each time you
IPL CONSULTATION AND LIABILITY DOCUMENTATION
Name...... Address:... Date of Birth:... Suburb:... Postcode:... Home Phone:... Mobile:... Email Address:... How did you hear about us?... Contact in case of emergency:... Place a tick in the areas of
Date: Date of Birth: Gender: Male Female. City: State: Zip: Caucasion a African-American Hispanic Asian East Indian American Indian
Contact Information: Date: Date of Birth: Gender: Male Female Name: Address: City: State: Zip: Home Phone: Work/Day Phone: Cell: Email: Emergency Contact: Emergency Contact Phone: Medical Background Ethnic
Radiant Skin Dermatology and Laser
Pre-op Instructions Before Surgery Wash your hair the day before surgery with Hibiclens and your regular shampoo, in a 50/50 ratio, let sit for a minute and then rinse out. Do not wash your hair the day
RINGING EARS AFTER ACCUTANE
RINGING EARS AFTER ACCUTANE Ringing Ears After Accutane How long do accutane blood test take to come back Accutane lawyer nebraska city newspress obituary Accutane how soon does it work Best eye drops
Hair Loss Treatment Regular Strength (Minoxidil)
Information for the user Hair Loss Treatment Regular Strength (Minoxidil) Read all of this leaflet carefully before you take this medicine because it contains important information you need to know. This
INFORMED CHEMICAL PEEL CONSENT. 1. I authorize the chemical peel listed above, to my face and / or neck, chest and hands.
INFORMED CHEMICAL PEEL CONSENT 1. I authorize the chemical peel listed above, to my face and / or neck, chest and hands. 2. Depending on the chemical peel site, there may be redness and/or irritation and
MANAGEMENT OF RADIATION INDUCED SKIN REACTIONS
Manchester Cancer MANAGEMENT OF RADIATION INDUCED SKIN REACTIONS One of the most common side effects of radiation is acute skin reaction which can range from mild erythema to confluent moist desquamation
scalp solution 5% w/v minoxidil cutaneous solution to be applied to the scalp
scalp solution 5% w/v minoxidil cutaneous solution to be applied to the scalp This medicine is used to treat hereditary hair loss in men aged 18 65 years. This product is for men only and should NOT be
Total Skin Electron Beam Therapy (TSEBT)
Total Skin Electron Beam Therapy (TSEBT) Radiotherapy A guide for patients and carers Contents When is total body electron radiotherapy used?... 1 Planning your treatment... 1 Treatment... 1 Radioactivity...
HEALTH HISTORY. Name Date DOB Age. Home Phone Work Mobile Other
HEALTH HISTORY To ensure both the effectiveness and the safety of your treatment, please complete this health history as accurately as you can. PERSONAL INFORMATION Name _ Date DOB Age Address _ City State
(Injection of collagen, hyaluronic acid or other filler materials) INFORMED CONSENT FOR DERMAL FILLER
INFORMED CONSENT FOR DERMAL FILLER (Injection of collagen, hyaluronic acid or other filler materials) INTRODUCTION Dermal fillers are injected just under the skin s surface in order to temporarily correct
Skin Reactions from Radiation Treatments
Skin Reactions from Radiation Treatments Skin reactions are a common side effect of radiation treatments. They are caused when repeated doses of radiation pass through the skin. Skin reactions occur within
COMMON CONTRAINDICATIONS FOR FACIALS
COMMON CONTRAINDICATIONS FOR FACIALS Ms. Wade Cosmetology Department Fullerton College PREVENTION The following conditions cannot receive a facial treatment: Viruses Bacterial Infections Fungal Infections
WHERE HEALING HAPPENS TWO-STEP HOSPITAL-GRADE SYSTEM RADIATION SKIN CARE
AT HOME WHERE HEALING HAPPENS TWO-STEP HOSPITAL-GRADE SYSTEM RADIATION SKIN CARE Cleanses, moisturizes and protects red, irritated skin Helps protect against redness, drying and peeling Radiation Dermatitis
Why should you self-care? How can my local pharmacist help? How your pharmacist can help
Be self-care aware Many common illnesses or symptoms are best treated at home with rest or with advice from a community pharmacist with no need to see a doctor or nurse. This leaflet contains advice and
Hair To Bare South. Client Name: Date:
Hair To Bare South Client Name: Date: I authorize Rachelle Stokes (Hair To Bare South) to perform the treatments. The purpose of these treatments is to diminish or remove unwanted hair. The quantity of
DON T LET HAIR LOSS TANGLE YOU UP: DERMATOLOGISTS CAN IDENTIFY COMMON HAIR DISORDERS AND OFFER SOLUTIONS
Jennifer Allyn Scott Carl Allison Sit (847) 240-1730 (847) 240-1701 (847) 240-1746 jallyn@aad.org scarl@aad.org asit@aad.org FOR IMMEDIATE RELEASE DON T LET HAIR LOSS TANGLE YOU UP: DERMATOLOGISTS CAN
ACCUTANE TO STOP OILY SKIN
ACCUTANE TO STOP OILY SKIN Accutane To Stop Oily Skin Accutane and liver damage Accutane for papulopustular rosacea Accutane covered by tricare Using vitamin c serum while on accutane Red hot face on accutane
Newport Cosmetic Center
Shirin Afrasiabi, M.D, Inc. 2301 Newport Blvd, Costa Mesa, Ca 92627 (949) 548-5700 Appointment: Initial. We require a valid Credit Card at the time of booking to secure your appointment Cancellation and
SALIBIAN MOSSI. Name Last First Middle. Address Apt. City State Zip. Home Phone Cell Phone Work Phone. Address
Name Last First Middle Address Apt. City State Zip Home Phone Cell Phone Work Phone Email Address Age Date of Birth Sex Height Weight Marital Status Drivers License # Social Security # Employer Occupation
Timeless Makeup, LLC
Timeless Makeup, LLC CLIENT REGISTRATION (Please complete all blanks) I. CLIENT INFORMATION Name Date Address City Zip Phone number Email address Type of work Ethnicity Date of birth What was your hair
Laser Skin Resurfacing what to expect
Laser Skin Resurfacing what to expect Laser skin resurfacing is a treatment to reduce facial wrinkles and skin irregularities, such as blemishes or acne scars. The technique directs short, concentrated
Would you like to receive informational updates, specials and newsletters? Yes No
Patient Contact Information Name Home Phone Work Phone Cell Phone Home Address City State Zip E-Mail Date of Birth Emergency Contact Name and Phone Who Referred You To This Clinic? Would you like to receive
Last Name: First Name: Address: City: State: Zip Code: Telephone: Home: Work: Cell: Date of Birth: Sex: Female Male
SCULPSURE MEDICAL HISTORY FORM Last Name: First Name: Address: City: State: Zip Code: Telephone: Home: Work: Cell: Date of Birth: Sex: Female Male Email Address: Family Doctor: Phone: Pharmacy: Phone:
HAIR LOSS. Types of Hair Loss
HAIR LOSS Hair loss is a common condition that affects most people (depending on the severity) at some point in their lives. Humans have between 100,000 and 150,000 strands hairs on their head. The number
PIERCING CONSENT RELEASE FORM PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING THIS DOCUMENT
PIERCING CONSENT RELEASE FORM PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING THIS DOCUMENT In consideration of receiving piercing from (Name of Practitioner)
Chameleon Medical Spa NEW CLIENT HISTORY
NEW CLIENT HISTORY This information will allow your professional skincare specialist to provide the optimum products and services. First Name: Last Name: Date: Birth date: Address: City: State:_ Zip code:
Cosmetic Surgery: Eyelid Surgery (Blepharoplasty)
Cosmetic Surgery: Eyelid Surgery (Blepharoplasty) This is a guide for people who are considering an eyelid surgery. We advise that you talk to a plastic surgeon and only use this information as a guide
Last Name: First Name: Address: Apt: City: State:
Today s date: Estimated Weight Height Last Name: First Name: Address: Apt: City: State: Zip Phone: (H): (C) (W) Email: Please note, email will not be given to others and will only used for reminders and
Maya Med Spa 6330 Broadway Blvd. Suite B, Garland, TX Name: Date of birth: Address: Pharmacy of your choice:
Client Consultation Name: Date of birth: Address: Home Phone: Cell Phone: Business Phone: E-mail address: Married: Yes No If yes, anniversary date: Employer: Occupation: Pharmacy of your choice: Does your
Enhancing your appearance with a facelift
PROCEDURE FACT SHEET PLASTIC SURGERY FACELIFT This is a guide for people who are considering a facelift surgery. We advise that you talk to a plastic surgeon and only use this information as a guide to
Pre and Post Procedure Information for Cosmetic Laser Skin Resurfacing with the DOT laser. James A. Rieger, MD (316)
Pre and Post Procedure Information for Cosmetic Laser Skin Resurfacing with the DOT laser James A. Rieger, MD (316)-652-9333 You have scheduled a delicate cosmetic laser procedure. The following information
VICKI HENKE MICROBLADING PERMANENT COSMETICS. What to expect in the healing process for all brow enhancement/permanent makeup procedures.
MICROBLADING/MANUAL PERMANENT MAKEUP TREATMENT BEFORE & AFTER CARE INSTURCTIONS What to expect in the healing process for all brow enhancement/permanent makeup procedures. WHILE YOUR SKIN HEALS, BE PREPARED
NEW PATIENT FORM. Full Name: Date of Birth Age : (First) (Middle) (Last) Address: (Street) (City) (State) (Zip code) Home #: ( ) Work Number : ( )
Office Use Only: Booker Mailchimp Referral Driver s License NEW PATIENT FORM Today s Date: Reason(s) for Today s Visit: Full Name: Date of Birth Age : (First) (Middle) (Last) Address: (Street) (City) (State)
S Main St, Kaysville, UT 84037
MEDICAL HISTORY Date Name Age Date of birth: Email: Address City State Zip Home Phone Work or CellPhone Preference number for contact (appointment reminders or other) Primary Physician s Name and Number
Press Kit: Primary Messaging
Press Kit: Primary Messaging The following points outline three key differentiators of Revanesse Versa TM. Using these points as a guideline and basis for content creation will help ensure product claims
Skin Allergy Testing Information
REinventing hair Skin Allergy Testing Information EVALUATION & COMPATIBILITY GUIDELINES 2 Permanent colour cream for uncompromising coverage and unbeatable retention. IGORA DUSTED ROUGE An authentic yet
ISOTREX GEL Isotretinoin 0.05% w/w
ISOTREX GEL Isotretinoin 0.05% w/w Consumer Medicine Information What is in this leaflet Please read this leaflet carefully before you use Isotrex Gel. This leaflet answers some common questions about
Chronic Telogen Effluvium. What is Chronic (Idiopathic) Telogen Effluvium or CTE? CTE one of a group of disorders known as hair shedding conditions
750 West Broadway Suite 905 - Vancouver BC V5Z 1H8 Phone: 604.283.9299 Fax: 604.648.9003 Email: vancouveroffice@donovanmedical.com Web: www.donovanmedical.com Chronic Telogen Effluvium What is Chronic
Pre-Treatment Advice and Procedures
Pre-Treatment Advice and Procedures 1) Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear crusty for up
AREA OF BODY TATTOO IS SITUATED?
CLIENT CONSULTATION LASER TATTOO REMOVAL FORM Address: Date of Birth: Suburb: State: Postcode: Telephone: Work: Mobile Home: Other: Email Address: How did you hear about us? Tattoo Removal Colours in tattoo
Scabies is a very common skin condition caused by an infestation of mites.
Scabies is a very common skin condition caused by an infestation of mites. The most common symptom is a very itchy rash, which may increase in severity if left untreated. Prescription topical creams and
Jeffrey S. Epstein, M.D., FACS. Pre and Post Operative Instructions for FUE Hair Transplants
Pre and Post Operative Instructions for FUE Hair Transplants Hair restoration is a delicate process and it is important that you understand the nature, goals, potential complications, and limitations of
SkinCeuticals Flagship Advanced Medical Spa
SkinCeuticals Flagship Advanced Medical Spa 570 Long Point Road Mt Pleasant, SC 29464 843-881-0320 Table of Contents Spa Personnel Platelet Rich Plasam (PRP) Treatment Instructions TruSculpt Treatment
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR PERMANENT MAKEUP
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR PERMANENT MAKEUP Name: DOB: Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Have you received chemotherapy
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING Name: DOB: Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Age Have you received chemotherapy
Endoscopic Brow Lift Post Op
Endoscopic Brow Lift Post Op RECOVERY TIMETABLE: Approximate recovery after endoscopic brow lift is as follows: DAY 1: Return home, leave any surgical dressing undisturbed until it is removed in the office.
Dr. Paul L. Leong PATIENT MEDICAL HISTORY
Fax: 412.226.5176 Dr. Paul L. Leong PATIENT MEDICAL HISTORY Name: Age: Appt. Date: Address: City: State: Zip Code: _ Email:Date of Birth: Phone Number: Home ( ) Cell ( ) Social Security # Sex: Male: Female:
Welcome to Bella! Give the Gift of Bella. A few tips to prepare you for your first visit: Gift Certificates are just $100 for a $150 value!
Welcome to Bella! We are glad to have you as our guest. We encourage you to visit our website to see all of the exciting new laser and skincare treatments that we offer. Please be aware of our 24 hour
100% Effective Natural Hormone Treatment Menopause, Andropause And Other Hormone Imbalances Impair Healthy Healing In People Over The Age Of 30!
This Free E Book is brought to you by Natural Aging.com. 100% Effective Natural Hormone Treatment Menopause, Andropause And Other Hormone Imbalances Impair Healthy Healing In People Over The Age Of 30!
Contraindications Pre and Post Instructions
Contraindications Pre and Post Instructions **VERY IMPORTANT---PLEASE READ** **It is very important you follow these rules as medical conditions can affect the outcome of your eyebrows. Please notify me
Wound care and treatment Burns (1st, 2nd and 3rd degree burns) Sunburn
1 of 7 15/10/2008 9:03 Home Products Shop Resources Testimonials Contact Pot of Gold skin balm and Pot of Gold baby balm are truly multi-purpose products which can be used for all your day to day skin
Daktacort 2% / 1% w/w cream
PACKAGE LEAFLET: INFORMATION FOR THE USER Daktacort 2% / 1% w/w cream Miconazole nitrate / hydrocortisone Daktacort is a registered trademark Read all of this leaflet carefully before you start using this
Beautiful You LLC. Laser Hair Removal Pre/Post Treatment Care
Beautiful You LLC Laser Hair Removal Pre/Post Treatment Care Pre-Treatment Instructions Avoid deep tanning, including tanning beds and tanning creams, 2 weeks before and 1 week after treatment. If you
EVERYONE WILL NOTICE. No One Will Know.
THE WORLD S #1 SELLING DERMAL FILLER COLLECTION EVERYONE WILL NOTICE. No One Will Know. Get the natural-looking, long-lasting results you desire. Ask your aesthetic specialist about JUVÉDERM today. Actual
NEWS RELEASE. CONTACTS: Investors: Lisa DeFrancesco (862) Media: Mark Marmur (862) Ember Garrett (714)
NEWS RELEASE CONTACTS: Investors: Lisa DeFrancesco (862) 261-7152 Media: Mark Marmur (862) 261-7558 Ember Garrett (714) 246-3525 JUVÉDERM VOLBELLA XC APPROVED BY U.S. FDA FOR USE IN LIPS AND PERIORAL RHYTIDS
COSMETIC INTEREST QUESTIONNAIRE
COSMETIC INTEREST QUESTIONNAIRE Patient Name: Date: General appearance or products of interest to you (please check all that apply). Skin care consult Facial veins Neck elasticity Skin care products Facial