Pre-Visit – Timeless Skin Care by Stacey

Before your visit please fill out the medical history form below to save time.

And download the Disclaimer form and Consent form to fill out beforehand. Or you can fill them during your visit.

MEDICAL HISTORY FORM

Name

Address

Home Telephone

Cell Telephone

Work Telephone

Date of Birth

Occupation

What vitamin supplements/ herbal remedies are you currently taing ?

Details of any known allergies:

Within the last two years, what surgery, if any, have you undergone ?

Any undiagnosed pain lumps or swellings?

Details of any condition (medical or otherwise) that has not been mentioned above.

What medication are you currently taking?

Are you taking HRT?

Yes No

Are you taking the contraceptive pill?

Yes No

Are you being treated or have you been treated with Oral Corticosteroids?

Yes No

If yes:What for/affected area

Are you being treated or have you been treated with Topica Corticosteroids?

Yes No

If yes:What for/affected area