Injectable Assessment Form Please fill out the following form for your assessment.First Name *Last Name *GenderPreferred PronounsOccupationCanadian Citizen/Permanent Resident?YesNoMB Health (6 digit #)0 / 6PHIN (9 digit #)0 / 9OtherStreet AddressCityState/ProvinceZIP / Postal CodeD.O.B.DayMonthYearPhoneWorkHomeCellWhat concerns would you like to address at your appointment?Forehead linesFrown lines between browsLow set brows/drooping eyelidsLines around mouthJowlsSmile lines/nasolabial foldsNecklace linesVolume lossHollowing to under eyesDarkness to under eyesDouble chin/neck fullnessSkin laxity or "looseness"Unwanted hairScarsSun damage/brown spotsRedness/rosaceaMoles/skin lesionsBlackheads/whiteheadsAcneExcessive oil/sebumDrynessOtherHave you had a consultation for any of the above concerns before?YesNoIf Yes please specify:Consent obtained to access past treatment recordsYesNoPlease describe past treatmentsWere you satisfied with past treatments?YesNoIf No please explain whyWhat skin care products are you currently using:Make-up removerCleanserExfoliatorTonerDay creamNight creamMoisturizerFace masksSerumsGrowth FactorsPigment Control creamsRetinolSPFUnder eye creamOtherMedical Conditions/Illness/Past Surgeries?YesNoIf Yes please specify:Medications (including Vitamins and Supplements)?YesNoPlease specify wich medicationsList all Allergies/Reactions?YesNoPlease specifyAre you allergic to wasp stings?YesNoUnsureIf Yes describe reaction:Medical Conditions/Illness/Past Surgeries?YesNoIf Yes please specify:Do you smoke tobacco?YesNoHow much per day?Do you consume or smoke marijuana?YesNoHow often?Do you have history of Cold Sores?YesNoHow often?Are you pregnant?YesNoBreastfeeding?YesNoDo you plan on becoming pregnant within the next 4 months?YesNoHave you had Filler/Hyaluronic Acid Injections?YesNoIf Yes please specify:Have you had Botox® Injections?YesNoIf Yes, last treatment date:Do you have history of Cold Sores?YesNoDo you use tanning beds/booths/self-tanner?YesNoAre you currently using Retin-A®/Retinol/Tazorac®?YesNoIf Yes please specify What strength? For how long? How frequently?Have you ever used any products that caused a bad reaction?YesNoIf Yes please describe reaction:How did you hear about our clinic?Magazine AdTikTokFacebookInstagramFriends/FamilyWebsiteGoogleReal Self / Rate MDOtherSpecifyThe above information is accurate to the best of my knowledge.DateDayMonthYearSignatureSend MessagePlease do not fill in this field. Get Access to Our Exclusive Monthly Specials Sign Up TodayFirst Glance Rewards® Join the First Glance Rewards Program®Collect points every time you visit. As a member, you’ll save on your favourite treatments. SubmitPlease do not fill in this field.
