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PATIENT IN-TAKE

This in-take is required yearly for all procedures. 

Gender Assigned At Birth Required
What services are you receiving? Required
Allergies: Check all that apply and describe any reactions you have experienced. Required
1. Are you pregnant or nursing? Required
2. Have you had any alcohol in the last 24 hours? Required
3. Have you ever had cold sores or fever blisters? Required
4. Have you had a laser or chemical peel within 6 months? Required
5. Have you ever had any pemanent cosmetics or tattoos? Required
6. Do you bruise easily for no obvious reason? Required
7. Do you routinely use Retin-A, glycolic, or other exfoliating products? Required
8. Do you wear contact lenses? Required
9. Are you allergic or sensitive to any metals? For instance, metals used in jewelry? Required
10. Do you have any problems healing? Required
11. Is your skin oily? Required
12. Do you use tobacco? Required
13. Do you have any heart conditions? Required
14. Are you diabetic? Required
15. Do you have any autoimmune disorders? Required
16. Are you sensitive or allergic to hand creams or body lotions? Required
17. Do you have your lips injected with filler materials? Required
18. Do you have Botox / Neurotoxin injections? Required
19. Do you menstruate? Required
20. Do you hyper-pigment (Tendency to develop dark spots on the skin from wounds or sun)? Required
21. Do you tend to develop keloid or hypertrophy scars? Required
22. Do you scar easily from minor injuries? Required
23. Do you have any seizure related conditions? Required
24. Do you tend to faint or become dizzy? Required
25. Do you bleed excessively from minor cuts? Required
26. Do you have prosthetic implants? Required
27. Do you consume aspirin daily? Required
28. Are you under treatment for depression? Required
29. Do you have any type of herpes? Required
30. Are you sensitive to petroleum-based products? Required
31. If you have had permanent cosmetics or tattoos, did you have any problems with heaing afterwards? Required
32. Are you undergoing radiation or chemo-therapy treatments? Required
33. Are you now, or have you ever been on the acne treatment Accutane? Required
34. Are you wearing a pacemaker? Required
35. Do you take prescription medications? Required
36. Are you anemic? Required
37. Do you have a history of skin sensitivities? Required
38. Do you have any medical conditions that have resulted in a medical professional requiring you to pre-medicate with an antibiotic prior to a dental or other invasive procedure? Required
39. Do you have allergies to makeup? Required
40. Do you have dry eyes? Required
41. Do you intentionally tan? Direct Sun / Tanning Bed? Required
42. Do you have a history of cancer? Required
43. Do you have a history of stroke or heart attack? Required
44. To your knowledge, are you allergic or resistant to over-the-counter-level numbing products such as ELA-Max? Required
45. Do you hypo-pigment (lack of pigment on the skin)? Required
46. Are you allergic to hair dyes? Required
47. Do you have arthritis? Required
48. Do you have low or high blood pressure? Required
49. Do you have sinus problems? Required
50. Have you experienced Hepatitis or Jaundice during the past 12 months? Required
51. Have you had any surgeries in the past 10 years? Required
52. Please list your ethnic background (Your ethnic background affects the body, skin and it's response to treatment.) Required
53. How would you describe your skin? Required
Thanks for submitting!

So Natural by Angela Durbin

1000 Des Peres Rd.

Suite 118

Des Peres, MO 63131

Call or Text: 314.485.9645

angeladurbinpc@gmail.com

​

 

HOURS
Monday ・ 9:00am - 5:00pm
Tuesday・ 1:00am - 6:00pm
Wednesday・ 9:00am - 3:00pm
Thursday:・9:00am - 5:00pm
Friday・ 9:00am - 5:00pm
Saturday・ By Appointment Only
Sunday・ Closed

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@ 1994, So Natural Institute. All Rights Reserved.

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