Consultation FormPlease fill out the Aesthetics MD Spa consultation form below. Please enable JavaScript in your browser to complete this form.Today's DateName *FirstLastDate of BirthEmail *PhoneAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhat is your main goal for today's treatment?Your SkinHave you ever had a facial or body treatment before?YesNoIf Yes, when?Do you have any special skin problems or concerns pertaining to your face or your body?YesNoIf Yes, please specifyDo you currently use Retin-A, Renova, AHA, or any Retional based products?YesNoIf Yes, please specifyHave you ever used any of the above ingredients on your skin?YesNoIf Yes, how long ago?Have you ever had chemical peels, microneedling, microdermabrasion, laser or dermalblading?YesNoIf so, whenHave you ever used any acne medication?YesNoWhen? and Which drug?What skincare products are you currently using? (List brands where known) Soap/CleanserTonerDay MoisturizerSPFExfoliator/ ScrubMaskEye ProductNight MoisturizerWhat areas of concern do you have regarding your SKIN? (Please check all that apply)Blackhead/WhiteheadsExcessive oil/shineRosaceaBroken capillariesRednessSun spots/ liver spotsWrinkles/fine linesDull/dry skinFlaky skinDehydratedEyes - Puffiness, Dark circles, WrinklesOtherHave you ever had any allergic reaction to any of the following?CosmeticsAHA'sMedicineFoodAnimalsDrugsPollenFraganceSunscreensIodineLatexShellfishSulphurOtherAre you taking any Oral Contraceptive?NoYesPlease specifyFemales Only: Do you have any menopausal concerns?YesNoIf Yes, please explainAre you undergoing any hormone replacement therapy?YesNoWhich one?E signatureI understand, have read and completed this questionnaire truthfully. I agree that this constuites full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin/body from treatments received. I am aware there are often inherent risks associated with skin/body treatments and that the services I am about to receive could have unfavorable results including, but not limited to: allergic reactions, irritations, burning, redness, scarring, soreness, etc. By signing below, I further agree that I will not hold Aesthetics MD LLC or its affiliates or any of its employees responsible should there be any unfavorable outcome or result.Submit Book Online Contact us Name Email Message Send message