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info@kamloopsskinsolutions.com

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CART

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Cosmetic ConsultationJennifer Cook2024-07-08T18:01:32-07:00

Cosmetic Consultation Client Form

Cosmetic Consultation PDF Form

Cosmetic consultations are not covered by the BC Medical Service Plan. $75 is charged for cosmetic consultations and this fee can be applied to any treatment or service (not product) if done within 30 days of consultation. There are no refunds for consultation fees.

If you choose the PDF option, print and complete the form at home and bring it with you to your appointment. Or scan your completed form and email it to us at info@kamloopsskinsolutions.com before you visit the clinic.

RETURN TO > BEFORE YOUR APPOINTMENT

Please use this simple and secure online form which is signed electronically and sent directly to us immediately upon completion.

Name *

First

Last

Personal Health Number *

Birthdate *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone Number to Reach You *

Email Address

Sign-up to our newsletter?

We occasionally send out news, invitations and special pricing offers. You can unsubscribe at any time.

Emergency Contact & Relationship *

Emergency Contact Phone *

Family Physician

Your Occupation

Current Medications *

Previous Surgeries *

Drug Allergies *

Latex Allergy? *

Height *

Weight. Please indicate lbs or kgs. *

How did you hear about us?

Word of mouth
Friend/client here
Instagram
Google/website
Facebook
Other

If other, please specify:

Lifestyle

Cigarettes? *

Cigarettes per day *

Years smoked *

Alcohol/drinks per week *

Exercise frequency per week *

Personal History

Personal History *

Heart disease
Seizures
Hypertension
Diabetes
Bleeding problems
Previous stroke/TIA
Cancer
Thyroid problems
Migraines
Other (please list in space provided)
None of these

If you chose "other", please list conditions

Have you ever been documented to be a carrier of an antibiotic resistant organism (ARO)? *

Do you actively tan (inside or outside)? *

If yes, when was your last session? *

Do you use Retinol *

If yes, how often do you use Retinol? *

Do you use Glycolic Acid *

Do you use Salicylic Acid *

Do you have a history of Rosacea? *

How do you manage? *

Do you have a history of Melasma? *

Brown or grey patches on skin

How do you manage?

Have you used Accutane? *

If yes, was this within the last 6-12 months? *

Have you been treated for skin cancer? *

If yes, when and where on your body? *

Have you been treated for Actinic Keratosis? *

Rough scaly patches on skin

If yes, when and where on your body? *

Have you EVER had a cold sore? *

If yes, when was your last outbreak? *

Do you have any immune disorders? Rheumatoid Arthritis, Scleroderma, Lupus? *