Potenza Consultation Form – Padra Registration

Potenza Consultation Form

PATIENT INFORMATION

Full Name *

Date of Birth *

Address *

Email *

Cell phone *

Secondary Phone *

SKIN DETAILS

Skin Type (Fitzpatrick Scale): *

Area(s) of Concern: *

Face

Lip

Body Treatment

MEDICAL HISTORY
Area(s) of Concern: *

Keloids

Excessive Scarring

Cold sore

Genital Herpes

Lymphedema

Active Acne

HPV

HIV

Infection

Hepatitis

Eczema

Dermatitis

Rashes

Epilepsy

Vitiligo

Pregnancy

Lactation

Crohn’s Disease

Hyperthyroidism

Psoriasis

Hormonal disorders

Anticoagulants Therapy

Autoimmune disease such as Lupus

Menstrual disorders

Active Sunburn/Taning

Melanoma or Lesions suspected Malignancy

Deep Venous Thrombosis

MEDICINE *

Isotretinoin (Roaccutane) (If “Yes” how long have you been using it?)Isotretinoin (Roaccutane) (If “Yes” how long have you been using it?)

Topical Medication (If “Yes” which medicine?)Topical Medication (If “Yes” which medicine?)

Antibiotics (If “Yes” which medicine?)Antibiotics (If “Yes” which medicine?)

Do you take any special medicine? (If “Yes” which medicine?)Do you take any special medicine? (If “Yes” which medicine?)

HAVE YOU RECENTLY:
Aesthetic: *

Fillers

Injectables

Laser Treatments

Had any recent exfoliation: *

Mechanical

Chemical

Moroccan bath

ALLERGIES AND SENSITIVITIES:

are you allergic to any topical products, medications or anaesthesia? *

Yes

Do you have Gold allergy? *

Yes

Have you experienced adverse reactions to previous cosmetic treatments? *

Yes

EXPECTATIONS AND GOALS

Are you aware of the potential discomfort during the procedure? *

Yes

Do you understand the need for multiple treatment sessions? *

Yes

Are you aware of the potential side effects and risks? *

Yes

POST-TREATMENT CARE

Are committed to following post-treatment instructions (e.g sun protection skin care)? *

Yes

Do you have any upcoming events or travel plans that may affect your recovery? *

Yes

CONSENT AND UNDERSTANDINGS

Have you received information about the procedure and its process? *

Yes

Do you understand the importance of sun protection during and after treatment? *

Yes

All of the information is true and accurate to the best of my knowledge.

Patient Signature *

Clear

Witness Name *

Clear

If you are human, leave this field blank.