New Patient Registration

Please fill out the form as completely as possible:

    Name (Nombre)*

    DOB (Fecha de Nacimiento)*

    Your Email*

    Procedures (Procedimientos)

    Please mark which concerns apply to you? (por favor marcar lo que quisiera mejorar):

    Skin Care (Cuidado de piel):

    What is your skin type (Que clase de piel tiene) ?

    Please check the products you currently use (Porfavor indicar productos que esta usando

    Medical History

    Allergies (alergias)

    Medication (medicamentos)

    Are you pregnant (Esta usted en estado) ?YesNo

    Have you ever had any of the following injectables or implants (Usted alguna vez ha tenido alguno de los siguientes productos injectado)?

    Other filler:

    Have you had an unusual reaction to any of these?
    (Usted a tenido alguna reacción inusual con algunos de estos productos)?
    YesNo

    If so please explain:

    Tell your doctor about your medical conditions
    (Por favor déjenos saber sus condiciones médicas):

    Have you been diagnosed with a disease that affects your muscles and nerves?
    (Usted esta diagnosticado con un condición que afecta sus músculos o nervios)?

    Such as (Como estas):

    Amyotrophic Lateral Sclerosis YesNo

    Myasthenia Gravis YesNo

    Lambert Eaton Syndrome YesNo