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.

* Indicates a required field.

Client Information
Salutation:
Mr.   Mrs.   Ms.   Dr.
*Full 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
VelaSHAPE™ Cellulite Treatment
Spider Vein Treatment
Photorejuvenation
Microdermabrasion
Skin Treatment
Pixel® Laser Resurfacing
CO2 Fractional Laser Resurfacing
Blue Light Acne Treatment
NuSurface Acne Scar Treatment
Accent XL Skin Tightening
Accent XL Fat Reduction
Vampire Facelift
iRevival Lift
Male Hormone Therapy
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
   
MALE HORMONE REPLACEMENT QUESTIONS:
   
*Fitness Level
   
Have You Noticed?
Decreased Sex Drive
Decreased Energy Levels
Loss of Strength
Loss of Endurance
Sexual Performance Issues
Work Performance Issues
Decreased Quality of Life
Changes in Body Composition
Increased Recovery Time
Decreased Mental Acuity
 
Choose Yes / No:
Have you ever benefited from HRT?
Yes    No
 
Do you know someone that has benefitted from HRT?
Yes    No
 
Are you Self Employed?
Yes    No
 
What is your occupation?
   
How much of a monthly
investment are you able
to budget to improve your
quality of life?



   
Other Questions:
*How did you find out
about our services?
   
Comments?
 
Free Consult Image


Internet Specials Button
Right Column Divider

NEWSLETTER SIGNUP

Sign up here for our newsletter and you will receive a

$50 gift certificate
instantly
     just for signing up!
Right Column Divider
View Videos Button