Admission form for Neuromodulator Treatment - Ste-Julie
Global Dent - Admission form for treatment with a neuromodulator
Date :
Last name:
First name:
Age:
Date of birth:
Phone / Cell phone:
Email:
Address:
City:
Zip code:
Health insurance number:
Expiration date:
Medical History
Please check all past or current medical conditions:
1. Previous injections of neuromodulators (Botox, Dysport, Jeuveau, Xeomin)?
2. Do you tend to develop thick, hypertrophic, or keloid scars—with or without hyperpigmentation—after cuts or burns?
3. Do you have any scars on your face?
4. History of facial surgery?
5. Do you bruise or bleed easily?
6. Have you had hair removal by tweezing, waxing, electrolysis, or depilatory cream in the past 4 weeks?
7. Have you used a tanning bed or been out in the sun in the past 4 weeks?
8. Have you used self-tanning products or spray tanning in the past 2 weeks?
9. Have you ever had skin cancer?
10. Do you use sunscreen with an SPF of 30 or higher every day?
11. Have you noticed any moles that have recently changed in appearance, itched, or bled?
12. Active skin infection?
Recent increase in body hair?
14. Seasonal allergies / allergic rhinitis?
15. Asthma?
16. Eczema?
17. Hepatitis?
18. Area ?
19. Do you have a cold sore?
20. Do you have genital herpes?
21. Migraines?
22. Have you ever had a photosensitivity disorder? (e.g., lupus)
23. Have you taken Accutane in the past 6 months?
24. Permanent makeup or tattoos? Where?
25. Are you currently taking antibiotics? Which ones?
26. Do you have a life-threatening allergy to anything?
27. Do you currently smoke?
28. Autoimmune disease? (e.g., rheumatoid arthritis, scleroderma)
29. Neurological or muscular disorder? (e.g., ALS, myasthenia gravis, Lambert-Eaton syndrome, or other)
30. Diabetes?
31. Heart problems?
32. High blood pressure?
33. Pacemaker?
34. Personal history of seizures?
35. Cancer?
36. HIV / AIDS?
38. Are you currently pregnant or is there a possibility that you may be pregnant?
39. Are you currently breastfeeding?
40. Do you currently have a tan in the area to be treated?
41. Do you have a history of keloid scarring or poor wound healing?
42. Do you have seasonal allergies or allergic rhinitis (hay fever)?
43. Are you currently using Retin-A or glycolic acid products?
I certify that the information provided is complete and accurate.
Patient initials
Date