Idealimage.com

Please introduce yourself.
Name: ________________________________________________________________________ Today’s Date: ________________
Birth Date: ______ /______ /______ Age: _______ qMale qFemale E-mail: __________________________________ Home Phone: ( ) ________________________________ Cell Phone: ( ) ____________________________________ Home Address: ______________________________________________________________________________________________ City: ______________________________________ State: ______________________________ Zip: ________________________ Occupation: _______________________________________ Business Phone: ( ) _________________________________ Spouse’s Name: _________________________________________________________ In case of emergency, please contact:
Name: __________________________________________________________________________________________________________ Phone: ( ) __________________________________ Cell Phone: ( ) ______________________________________ May we share your medical information with this person? qYes qNo Please list anyone else we can share your medical information with: __________________________________________________ ____________________________________________________________________________________________________________ Where did you hear about Ideal Image®?
qFriend or Family Member, Name: ____________________________________________________________________________ qPhysician Referred, Name: __________________________________________________________________________________ qRadio qTV qBillboard qMagazine/Newspaper qInternet qLocal Event qOther __________________________ How do you preferred to be contacted? qPhone qE-mail qText Message Would you like to receive special offers and promotions from Ideal Image® via e-mail? What are your three favorite radio stations? _____________________________________________________________________ What are your three favorite web sites? ________________________________________________________________________ We do not sell any customer information to any third party. Neither do we provide any individually identifiable customer information to any third party except as follows: in response to sub-poenas, court orders or legal process, in order to finalize a payment for services requested and agreed to with your personal Ideal Image® consultant. This information may be shared with your financial institution or credit card issuer as indicated.
GIF - Version 063010 | 2010 Ideal Image Development, Inc.
Name ____________________ Chart# ____________________ Please tell us about yourself.
Have you ever had laser treatments or Electrolysis? Procedures/Areas treated: _____________________________________ Any complications? _____________________________ Please Circle The Areas You Need Treated On The Diagram Below
In order to better establish your skin type, please tell us your race/ethnicity: ___________________________________
Please Check The Box That Best Describes Your Skin Type:
Never tans, always burns (extremely fair skin, blonde hair, blue/green eyes) Occasionally tans, usually burns (fair skin, sandy/brown hair, green/brown eyes) qSkin Type III Often tans, sometimes burns (medium skin, brown hair, brown eyes) qSkin Type IV Always tans, never burns (olive skin, brown/black hair, dark brown/black eyes) qSkin Type V Never burns (dark brown skin, black hair, black eyes) qSkin Type VI Never burns (black skin, black hair, black eyes) GIF - Version 063010 | 2010 Ideal Image Development, Inc.
Name ____________________ Chart# ____________________ Medical history
How would you describe your general health? Have you had a major illness or been hospitalized within the last 5 years? qYes qNo Please describe: _____________________________________________________________________________________________ Are you currently using any medications? (Topical, Ingestible or Injectable) qYes qNo List all medications and conditions: _____________________________________________________________________________ Have you taken Accutane in the last 6 months? qYes qNo Are you using Rogaine, Propecia, Minoxidil? If yes, please list: ___________________________________ Do you have any tattoos and/or permanent makeup? qYes qNo If yes, where? ______________________________ qYes qNo Please list: _____________________________________________ Are you taking Aspirin, Advil, Motrin or any other over the counter medications? qYes qNo List: ________________________________________________________________________________________________________ Are you taking any herbal or vitamin supplements? qYes qNo List: ____________________________________________ Do you use tobacco? qYes qNo Type: __________________________________________________________________ Do you consume more than two alcoholic beverages per day? qYes qNo Have you ever had any of the following:
What type: qBasal Cell qDysplastic Nevus qSquamous Cell qMelanoma If yes, when: _______________________________________ Where on the body: _________________________ Was it treated and how? ________________________________________________________________________ GIF - Version 063010 | 2010 Ideal Image Development, Inc.
Name ____________________ Chart# ____________________ Have you ever had any of the following:
qLiver Disease/Hepatitis (A, B, or C) qKeloid Scarring qVasculitis with/without skin involvement qHormone/Thyroid Disorder qAbnormal Blood Pressure (high or low?) qConnective Tissue Disorders qAnemia qAllergy to Lidocaine or other "caines" qBleeding Disorder Please describe or explain any of the above: ________________________________________________________________________________________ Have you ever had any surgical procedures? Please describe: _____________________________________________________________________________________________ Have you ever had any of the following treatments: qChemical Peel qGlycolic Peel qMicrodermabrasion qCosmetic Surgery qOther: ___________________________________________ What skin care products are you using? (Cleanser, Moisturizer, etc.) _________________________________________________ ____________________________________________________________________________________________________________________ Do you use or have you ever used any of the following products? qRetin A qAHA qHydroquinone qOther: _________________________ Any reactions? ____________________________________________________________ Is there any other information about your health that we should know? ______________________________________________ ___________________________________________________________________________________________________________________ WOMEN ONLY: Are you pregnant? qYes qNo
Expected Delivery Date: __________ /__________ / ___________ Are you trying to become pregnant? qYes qNo Are you taking oral contraceptives? qYes qNo Patient Signature: ___________________________________________________ Date: ________ /________ / ________
Person responsible for account (If under 18)
Parent/Legal Guardian Signature: _______________________________________ Date: ________ /________ / ________
OFFICE USE ONLY:
Confirmed for treament by: __________________________________________________ Date: ________ /________ / ________ Treatment Provider/Medical Director Signature GIF - Version 063010 | 2010 Ideal Image Development, Inc.

Source: http://www.idealimage.com/services/pif/Ideal-Image-GIF-Form-063010.pdf