13577 Feather Sound Dr., Suite 350 Clearwater, FL 33767 Call us at: +727 571 1923 Text us at: +727 263 4798 info@skinspirations.com

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New Patient Registration

Patient Registration

First name*
Last name*
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How did you hear about us?*
Answer from above
Please check any of the areas below from which your ancestors originated.
- Africa
- North America (you have some American Indian)
- Mexico, Central or South America
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- France, Germany, Poland & vicinity
- Scandinavia
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- Spain, Italy, Greece & vicinity
- Other (please specify area/s below)
Area not included above
Please list any allergies to medications below.
- I have no known allergies
My allergies are:
Please check any medical conditions below for which you have been treated.
- Anxiety or depression
- Asthma or chronic bronchitis
- Autoimmune or connective tissue disease (please specify type below)
- Bleeding disorder (please specify type below)
- Cancer (please specify type below)
- Cold sores
- Diabetes
- Heart Disease or arrhythmia
- Hepatitis B or C
- HIV
- Keloid or hypertrophic scarring
- Hypertension
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- Thyroid disease (please specify type below)
- Other (please specify type below)
Type of condition checked above
Type of condition checked above
Please list any prescription medications you're taking.
Do you smoke cigarettes or have you smoked in the last six months?
- Yes
- No
Please check any of the following treatments you've had in the past.
- Accutane
- Blepharoplasty or rhinoplasty
- Botox, Dysport, Jeuveau or Xeomin
- Dermal filler (please specify type below)
- Face or brow lift
- Fat reducing device or injection (please specify type below)
- Fat transfer
- IPL
- Laser skin resurfacing (please specify type below)
- Laser tattoo or hair removal
- Liposuction
- Medium depth or deep chemical peel
- Scar treatment (please specify type below)
- Vein reduction or removal
- Other (please specify type below)
Type of treatment checked above
What is the primary topic you'd like to discuss during your first consultation?
Which of the following are of interest to you even though they're not your primary concern today.
- Acne breakouts
- Wrinkles, lines, +/or crepey skin
- Large pores, blackheads & oily skin
- Brown spots, redness or blotchy pigment
- Dark eye circles or bags
- Fat reduction or body contouring
- Unwanted veins, hair or tattoos
- Feature enhancement or correction
- Knee or shoulder arthritis
- Tendonitis or plantar fasciitis
- Hair loss or thinning hair
- Professional skincare strategy
- Scars
- Sagging skin
- Sun damage, poor skin texture
Specify type checked above
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Main Office 13577 Feather Sound Drive, Suite #350 Clearwater, Florida 33762 727.571.1923 727.263.4798
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