New Patient Evaluation V2

New Patient Evaluation
First Name
Last Name
Email
Patient email on file
DOB
Signs of Facial Weakness?

YesNo
Are eyelids & eye brows symmetrical?

YesNo
Notes
List

Facial ScarsMalasmaBlemishesLesionsOther
Mental Status: Appropriate affect and demeanor

YesNo
Cosmetic Evaulation

Horizontal Forehead WrinklesVertical Glablellar WrinklesCrows FeetBunny Lines 4Nasolabial FoldsMid Face PtosisLack of Cheek VolumeThin/Asyemmetric LipsSkin LaxityOral CommissuresAcne or Acne Scars
CLEARED for all the treatments as circle YES.

I certify that I have reviewed patient medical history and examined the patient.
Patient Fitzpatrick
Risk alternatives and benefits were explained to the patient in detail. All questions were answered andpatient wishes to proceed with the treatments as outlines above per the protocol. This patient is CLEARED for all the treatments as circle YES

IIIIIIIVYES
I certify that I have reviewed patient medical history and examined the patient.
Comment
Provider Name
Signature

Clear
Date of Exam

MonthDayYear
Date
Botox

YesNo
Dysport

YesNo
Fillers

YesNo
Kybella

YesNo
Microneedling RF

YesNo
Pico

YesNo
Tatto Removal

YesNo
CO2

YesNo
IPL

YesNo
Laser Facial

YesNo
Laser Facial Removal

YesNo
DRP

YesNo
Hair DRP

YesNo
Sculpsure

YesNo
Exilis

YesNo
EmSculpt

YesNo
Microneedling

YesNo
Exosome

YesNo
Diamond Glow

YesNo
Dermaplane

YesNo
Femmine Rejuvination

YesNo
Carbon Facial

YesNo
Physician/ NP/ PA Name
Physician/ NP/ PA signature

Clear
Physician/ NP/ PA Name
Date

MonthDayYear
Date
Should be Empty:

New Patient Evaluation