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Good Faith Exam
RX Prescription Form
HIPAA Patient Form
Good Faith Exam
Nu-Derm Program Consent
Latisse Patient Consent
Skin Tone Enhancement System Consent
Tretinoin Consent
Good Faith Exam
Note: this is a confidential record of your medical history. Information collected here is for the sole use of Skin Deep. Information collected here will not be released to any person without your written authorization. Orders for prescription-strength products cannot be completed without these forms.
Which of the following prescription products would you like to purchase? Check all that apply:
*
Biafine Trolamine Topical Emulsion
Latisse
Obagi Nu-Derm Blender
Obagi Nu-Derm Clear
Obagi Nu-Derm Transformation Kit (any size)
Obagi Tretinoin Cream (any strength)
Skin Deep Hydroquinone Powder
Refissa (any size)
None of these
Personal and Contact Information:
Patient's Name
*
Email
*
Home Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Alternate Phone
Work Phone
Occupation
Sex
*
Male
Female
Your Health:
Within the last year, have you been under a dermatologist’s or other physician’s care?
*
Yes
No
If yes, please specify:
Do you have a history of cold sores?
*
Yes
No
Please list your current medications, or state "none":
*
Have you started any new medications since the last time you filled out this form?
*
Yes
No
Tell us about any allergies that you have, or state "none":
*
Do you smoke?
*
Yes
No
Consume alcohol?
*
Yes
No
Do you visit a tanning salon?
*
Yes
No
Do you exercise?
*
Yes
No
Do you follow a restricted diet?
*
Yes
No
Do you wear contact lenses?
*
Yes
No
Do you have metal implants, a pacemaker or body piercings?
*
Yes
No
Rate your level of stress on a scale of 1 to 5 (1 = low stress, 5 = high stress)
*
Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks?)
*
Yes
No
Your Skin:
Do you use SPF (sunscreen)?
*
Yes
No
If yes, indicate what SPF you use on your face and/or body:
Do you burn easily in moderate sunlight?
*
Yes
No
Do you have a tendency to redness?
*
Yes
No
Do you ever experience burning, itching or stinging sensations on your skin?
*
Yes
No
Have you ever used any of the following? Check all that apply:
*
Retin A
Hydroquinone
Accutane
Zovirax
Valtrex
None of these
If yes to any of the above, explain any negative reaction:
Have you ever had any of these procedures? Check all that apply:
*
chemical peel
waxing
electrolysis
facial surgery
none of these
If yes to any of the above, explain any negative reaction:
Describe your specific concerns/challenges with your skin, or state "none":
*
Which of these do you currently use for your face? Check all that apply:
*
soap
cleanser
toner
moisturizer
masque
exfoliator
eye products
none of these
For your body? Check all that apply:
*
soap
shower gel
scrubs
oil
moisturizer
depilatory products
self-tanners
none of these
Are you currently using any products that contain the following ingredients? Check all that apply:
*
glycolic acid
lactic acid
any exfoliating scrubs
any hydroxyl acid products
Vitamin A derivatives (i.e., Retinol)
none of these
Do you ever experience these conditions on your skin?
*
flakiness
tightness
obvious dryness
none of these
Female Clients:
Are you pregnant or lactating?
*
Yes
No
Not Applicable - Male Patient
Are you taking oral contraceptives?
*
Yes
No
Not Applicable - Male Patient
Are you currently having or due for your menstrual period?
*
Yes
No
Not Applicable - Male Patient
Male Clients:
Do you have any shaving challenges? If yes, specify, or state "none":
*
Please sign and date the form:
Patient Signature
*
Date
*
Date Format: MM slash DD slash YYYY
