Dr Sandhu's Aesthetic Clinic

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Home
About Dr. Sandhu
Services
- Our Services
- Men’s Health
Contact
- Request Appointment
- Patient History
Financing

Home
About Dr. Sandhu
Services
- Our Services
- Men’s Health
Contact
- Request Appointment
- Patient History
Financing

Patient History Form

Please fill out the following details about your medical history so we can assist you better

Full Name *

Email Address *

Phone Number

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of Birth

Gender

Family Doctor

Preferred Pharmacy

Emergency Contact

Do you have any chronic medical condition we should know about?

If Yes, please explain in detail

Are you currently under a doctor's care?

If Yes, please explain in detail

Have you ever had cancer?

If Yes, please specify what type and last date of treatment

Have you ever Chemotherapy or Radiation Therapy?

Please list allergies (if any) to medication, latex, or other substances

Please list medications (if any) that you take/use

Are you/could you be pregnant?

Are your menstrual periods regular?

Do you have any history of herpes 1 or 2?

Do you have any history of keloid scarring?

Have you taken any Accutane/any anticoagulant in the last 6 months?

Do you have any permanent makeup/implants/any tattoos?

If Yes, please list locations

Have you had any unprotected sun exposure, used tanning creams or tanning bed in the last 4-6 weeks?

Please describe what brings you here

Please select all that apply:Lines around eyesLines between eyes (angry look)Lines on foreheadPuffy eyesThin lipsDry SkinOily SkinLooking TiredCrease-nose to corner of mouthShort fragile eyelashesFrown or down-turned mouth (sad look)Brown spots on face/bodyRed, blotchy skinExcess skin above eyesThin Face/No cheeksCrepey SkinSunken-in eyesUnwanted body fatAging handsWrinkled neckAdult AcneBroken blood vessels on faceSpider Veins on legs

Please select all that are part of your skincare regimen:CleanserTonerMoisturizerSunscreen/SunblockTreatments (Retin A, Vitamin C+E, Bleaching Cream, etc.)

Please provide the names of skincare products that you use:

Your Signature

Today's Date

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