Creekside Laser Aesthetics

New Patient Information

___ Acne Treatment

___ Botox to Flatten and Prevent Wrinkles

___ Enhanced Skin Rejuvenation

___ Collagen Augmentation

___ Wrinkles

___ Skin Toning or Pore Size Reduction

___ Facial Redness

___ Brown Spots

___ Sun Damage

___ Broken Capillaries

___ Spider Veins/Leg Veins

___ Hair Removal

___ Shaving bumps/ingrown hair

Please put a check mark next to a past or current medical condition:

Medical History:

___ Lupus or other auto-immune deficiency (A)

___ Pregnant (A)

___ Bleeding abnormalities (A)

___ Treatment with Accutane® in the last
six months (A)

___ Kelloid or very thick scarring (A)

___ Psoriasis or Vitiligo (A)

___ Pulmonary embolism/blood clot (V)

___ Leg ulcer or Phlebitis (V)

___ Blood thinning medication (V)

___ Rheumatoid Arthritis “Gold” Therapy (A)

___ Cystic Acne (P)

___ Herpes simplex or fever blisters (A)

___ Diabetes (A) 

___ Epilepsy (A)

___ Scars that turn white or brown (A)

___ Dark spots after pregnancy, skin injury (A)

___ HIV (A)

___ Hepatitis (A)

___ Waxing/Plucking/Electrolysis within last
four weeks (HR)

___ Hirsutism (HR)

___ Transplant Anti-Rejection Drugs (HR)

___ Chemical Peels, Dermabrasion, Laser Resurfacing or Face Lift (A)