Spectrum Aesthetics - Upload Photos for Online Evaluation (Consultation)

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Picture #1 - Face Front*
Accepted file types: jpg, gif, png, jpeg.
Hands down - straight up - look at the camera
Picture #2 - Turn to Left Side*
Accepted file types: jpg, gif, png, jpeg.
Hands down - straight up - look at the side
Picture #3 - Turn to Right Side*
Hands down - straight up - look at the side
Picture #4 - Turn looking Back*
Accepted file types: jpg, gif, png, jpeg.
Hands down - straight up - turn your back to camera
Main Information
Name*
First Last
Phone*
Email*
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Height*
Weight*
Date of Birth*
Sex*
Medical History Form
All Questions Require An Answer - Please Write "N/A" If Not Applicable
Do You Have Any Drug Allergies? If So Please List:*
Do You Take Any Medications, Supplements, Vitamins, Or Birth Control (Including IUD & Patches)? If So Please List:*
Do You Currently Have Any Medical Conditions Or Have You Had Any In The Past? (Ex: Anemia, Asthma, Hyperthyroid, Hypertension, Diabetes, Cancer, Hepatitis, HIV, Etc. ) If so please list:*
Any Family History Of Cancer? If so What Type & What Family Member?:*
Have You Ever Been Hospitalized? If so for What & When ?:*
Do you have any history of DVT or Pulmonary embolism? :*
Please List All Medical, Surgical, & Cosmetic Procedures You Have Ever Had*
Please List All Pregnancies, Miscarriages, And Abortions With Date ( Please Note Procedures Must Be 1 Year Post Full Term Pregnancy & 8 Weeks Post Abortions:*
Do You Consume Alcohol? If So How Often?*
Do You Use Any Type of Recreational Drugs? If So Please List Which, How Often & When was the last date of use?*
Do You Smoke, Chew, or are Exposed to Second Hand Smoke of any Form Of Nicotine?*
Do You have Sickle Cell Disease or Sickle Cell Trait? (If so please state which one):*
Do you have any children?*
Procedure Details
Procedure Of Interest*
Date of Interest*
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Upload Photos for Evaluation

Main Information

Medical History Form

Procedure Details

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