Skin Deep Colorado
3207 N. Academy Blvd. Suite 309
Colorado Springs, CO 80917

Penrose Community Hospital Professional Building

719-597-1885 fax 719-597-1247

*Patient Name:
Birth Date:
Email Address:
*Address:
*State:
*Zip Code:
*Contact Phone: (cell phone # or confidential #):
Primary Care Provider:
Do you see a physician at Associates in Women’s Care? Yes    No
How did you hear about us?
Reason for visit
(Please select the areas you are interested in treating).		 Hair Reduction
Vein Reduction
Botox Injections
Acne
Cosmeceutical Consultation
Dermal Fillers
Skin Rejuvenation
Microdermabrasion
Chemical Peel
Rosacea Treatment
Please select any of the above treatments you have had in the past: Hair Reduction
Vein Reduction
Botox Injections
Acne
Cosmeceutical Consultation
Dermal Fillers
Skin Rejuvenation
Microdermabrasion
Chemical Peel
Rosacea Treatment
Past Medical History (Check those that apply) Asthma
Eczema/Rosacea
Impetigo
Psoriasis
Heart Disease
Diabetes
Skin Cancer
HIV/AIDS
Lupus
Bleeding History
Are you pregnant? Yes    No
Have you ever had a cold sore (herpes)? Yes    No
List other health problems:
Medications you are on:
Allergies:
Skin sensitivities:
Skin care products you now use:
Do you suntan or use a tanning booth? Yes    No
When was the last time you tanned?
Do you use self/tanning lotions? Yes    No
If so, when was the last time used?
Are there any concerns we should know about?

Terms and Conditions
Please read and sign below.

I understand it is important to provide true and accurate information regarding my current and past medical condition in order for the staff at Skin Deep Colorado to appropriately evaluate, advise and treat me. Failure to do so may increase my chance of complications, inadequate response or other adverse effects. I have answered the above information to the best of my knowledge.

By selecting this box, I agree to these Terms and Conditions.
I do not agree to these Terms and Conditions.