Are you currently being treated for a condition not listed? Please specify
Are you currently taking any physician prescribed medications? If yes, please specify.
Do you have any implants, tattoos or permanent makeup in the area to be treated? If yes, please specify.
Do you have any allergies? If yes, please specify.
Have you ever been treated by an endocrinologist? If yes, please specify.
Have you used or are you currently using Retin-A? If yes, please specify
What products are you currently using on your skin?
Have you ever or are you currently using Accutane? If yes, please specify.
Have you had a major surgery performed in the last 3 months? If yes, please specify.
Have you ever had any laser treatments or chemical peels in the last 6 months? If yes, please specify.
For women, when was your last menstrual cycle?
Are you currently pregnant? If so, when is your due date?
I understand Minneapolis Skin Clinic requests a minimum 24 hour advance notice when rescheduling or cancelling an appointment to avoid a cancellation fee. No shows, no calls, or appointment cancelled without 24 hours notice will be subject to a $50 missed appointment fee.
Please initial here