Intake Form New Patient Xthetics Face & Body Sculpt

Name (Required)

Do you suffer from any skin infection such as herpes or acne?

Do you have any skin condition, including vitiligo, psoriasis, lupus?

Do you have any history of cold sores or shingles?

If yes, how frequently, and where do these occur?

Do you have any scarring problems?

Are you currently under the care of a physician?

Have you had any current or previous medical problems?

Are you being treated for an infection with antibiotics or antivirals or have you been on treatment recently?

Are you currently taking any blood thinners (i.e. aspirin, warfarin, or any other anticoagulant)?

Have you had any other cosmetic treatments before?

Do you know the name of the product injected?

Did you have any side effects after the treatment?

Do you use any skincare products?

If yes, what skincare products do you use?

Anything else you would like to tell us?

Submit