Thank you for your interest in Advanced Skin Fitness. To receive a free consultation, please complete the following form to help us better understand your cosmetic skin care needs. We will be able to more effectively determine a treatment protocol to discuss with you before your first in-office consultation. We will contact you within 48 hours.

Client Information
Salutation:	Mr.   Mrs.   Ms.   Dr.
Full Name:
Preferred Name:
Date of birth: (mm-dd-yy)
Gender:	Male   Female
Contact Information
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Mobile Phone:
E-mail:
Preferred contact method:	Home Phone Work Phone Mobile Phone
Treatment Information
Which treatments would you like to have performed?	Laser Hair Removal VelaSmooth™ Cellulite Treatment Spider Vein Treatment Photorejuvenation Microdermabrasion Skin Treatment Pixel® Laser Resurfacing Blue Light Acne Treatment Stretch Marks Accent XL Skin Tightening Accent XL Fat Reduction Other Skin Care Services. Please specify:
Medical History
Please check any of these conditions that apply to you now:	Diabetic Pregnant
Have you been on Accutane in the last 6 months?	Yes    No
Have you ever had a malignancy?	Yes    No
Do you have a bleeding disorder or bruise easily?	Yes    No
Do you have fragile/intolerant skin?	Yes    No
Do you have Phlebitis (blood clots)?	Yes    No
Do you wear a pacemaker/defibrillator?	Yes    No
Please check if you are taking any of these medications:	Acne medication (Accutane, Accutane derivative, etc.) Anti Cancer Drugs Anti Depressants Antihistamines (Benadryl, Claritin) Anti-Inflammatory (Naprosen, etc.) Antibiotics Antipsychotics Diuretics Herbals (St. John's Wort, etc.) Hormones (Birth control pills, etc.) Hypoglycemics Other. Please specify:
What is your approximate height?
What is your approximate weight in lbs.?
Is your frame small, medium, or large?	Small Medium Large
Questions or comments:
Laser Hair Removal
What color is the hair you wish removed?	Black Brown Light Brown Blonde Light Blonde    Grey White Red
Please describe its growth:	Heavy/Dense/Coarse Medium Growth Sparse/Light/Fine
Which body areas would you like treated?	Face Chest Arms Back Underarms    Abdomen Bikini Toes Legs Neck Chin Jocky Line (men's bikini) Lip Anal Cleft Buttocks Ears Brow Scrotum/Penis Other. Please specify:
Do you prefer a male or female technician?	Male Female No Preference
Please describe your skin tone:	Type I   Always burn, never tan (extremely fair skin/blonde hair, blue/green eyes Type II   Usually burn, tan less than about average (fair skin, sandy brown hair, green/blue eyes) Type III   Sometimes mild burn, tan about average (medium skin, brown hair, green/brown eyes) Type IV   Rarely burn, tan more than average (olive skin, brown/black hair, dark brown/black eyes) Type V   Moderately pigmented, tans profusely (dark brown skin, black hair, black eyes) Type VI   Deeply pigmented, never burns (black skin, black hair, black eyes)
Have you had either laser hair removal treatment or electrolysis before?	Yes    No
If so, please tell us your results:
Fat Reduction and Cellulite Treatments
What areas would you like to be treated?	Upper Arms Abdomen Buttocks Outer Hips Rear Thigh Front Thigh
Have you tried other cellulite treatments in the past?	Yes    No
If so, please tell us your results:
Do you exercise?	Yes    No    Sometimes
Do you watch your diet?	Yes    No    Sometimes
Spider Vein Treatments
Please tell us what areas you have spider veins/varicose veins.
Have you had treatments in the past?	Yes    No
If so, please tell us your results:
Are the veins less than 2mm in thickness?	Yes    No
Skin Treatments/Microdermabrasion
Have you ever had a microdermabrasion treatment?	Yes    No
Do you or have you ever suffered from acne?	Yes    No
Have you ever had an chemical or acid peel?	Yes    No
Are you interested in looking younger or improving the overall look of your skin?	Looking younger Improving the overall look
Are you currently having professional skin treatments or facials?	Yes    No
What products do you currently use on your skin?
Do you currently wear a sunscreen daily?	Yes    No
Would you like information about reducing fine lines and wrinkles and tightening your skin?	Yes    No
Have you ever had Botox treatments or fillers?	Yes    No
Would you like to even out the tone of your skin or reduce sun damage?	Even out skin tone Reduce sun damage
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