Aesthetic Patient Information

Patient’s Name: __________________________________________ Date:______________________

Do you have or have you ever had any of the following?

Heart Disease ____Yes ___NO Skin Disease ____Yes ___NO
Kidney Disease ____Yes ___NO Bleeding Disorder ____Yes ___NO
Latex Allergy ____Yes ___NO Diabetes ____Yes ___NO
Hepatitis ____Yes ___NO Stroke ____Yes ___NO
Respiratory Disease ____Yes ___NO Respiratory Condition ____Yes ___NO
Severe Depression ____Yes ___NO Trying to Become Pregnant ____Yes ___NO
Needle Phobia ____Yes ___NO Nursing Baby / Child ____Yes ___NO
Increased Pain Before
or During Menses ____Yes ___NO

Please explain any ‘Yes” responses above: _________________________________________________________

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Please list any other Disease / Condition not listed above or that YOU consider important:
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Please list ANY disease / condition YOU are currently or were RECENTLY treated for:
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Please Note that patients attempting to become pregnant, are Pregnant, Breastfeeding, suffer from Insulin
Dependent Diabetes, Hepatic Cirrhosis, Kidney disease [Insufficiency / Failure], Stroke, Cancer, on
Chemotherapy or Anticoagulants {Plavix, Coumadin, Asparin, etc.} ARE NOT eligible to receive
MESOTHERAPY. Please discuss this matter with us, so that we can determine what other / alternative
treatments may be available for you.

List all medications , Herbs, Vitamins, and Supplements taken in the last two weeks:
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Please List Any ALLERGIES:______ NONE
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List all cosmetic treatments you have had [surgical and non-surgical]: ____ NONE
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The results were: _____Satisfactory; other: ____________________________________________________
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What concerns bring you here today:?_____________________________________________________________
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What are your expectations: _____________________________________________________________________
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I understand that the above information is completed correctly to the best of my knowledge. I understand that if I have
any changes in the above information or my medical status, that it is MY responsibility to notify Dr. Garcia or Utopia
Wellness Staff as soon as possible before any further treatment.

I understand that aesthetic treatment for cosmetic reasons are not covered by insurance companies and that payment is
due at the time the servicez(s) is /are rendered.

Patient Signature: ____________________________________________________ Date: __________________

Witness: __________________________________________________________ Date: __________________:

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 Please highlight the area(s) you desire treated

PATIENT NAME : _________________________________________________ DATE: _______________

Comments:
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Patient Initials: ________________

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 Please highlight the area(s) you desire treated

PATIENT NAME : _________________________________________________ DATE: _______________

Comments:
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Patient Initials: ________________

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 Please highlight the area(s) you desire treated

PATIENT NAME : _________________________________________________ DATE: _______________

Comments:
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Patient Initials: ________________

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 Please highlight the area(s) you desire treated

PATIENT NAME : _________________________________________________ DATE: _______________

Comments:
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Patient Initials: ________________

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 PHOTOSENSITIVE MEDICATIONS
Please circle any medications that you are taking or recently have been taking
ACNE MEDICATIONS ANTI-INFLAMMATOR
isotretinoin (Accutane) celecoxib (Celebrex)
tretinoin (Retin-A) ibuprofen (Motrin)
naproxen (Naprosyn)
ANTI-ARTHRITICS
Gold salt thiomalate (Solganol) ANTIBIOTICS
Azithromycin (Zithromax)
ANTINEOPLASTIC MEDICATIONS demaclocycline (Declomycin;others)
ANTICANCER MEDICATIONS doxycycline (Vibramycin;others)
dacarbazine (DTIC-Dome) griseofluvin (Fulvicin-U/F;others)
fluorouracil (Fluoroplex;others) hexaclorophene
methotrexate (Mexate;others) lomefloxacin (Maxaquin)
vinblastine (Velban) methacycline (Rondomycin)
nalidixic acid (NegGram;others)
ANTIDEPRESSANTS oxytetracycline (Terramycin;others)
amitriptyline (Elavil;others) quinolones
bupropion sulfonamides
clonipramine sulfacyntine
desipramine (Norpramin,Petrofrane) sulfamethazine
doxepin (Adapin,Sinequan) ulfamethizole
fluoxetine (Prozac) sulfamethoxazole-trimethoprim (Bacrtim,Septra)
imipramine (Tofranil) sulfasalazine
maprotilin sulfathiazole
emirtazapine (Remuron) sulfisoxazole (Gantrisin)
nortriptyline (Aventyl,Pamelor) tetracyclines
paroxetine (Paxil)
protriptyline (Vivactil) ANTIPSYCHOTICS
sertraline (Zoloft) chlorpromazine (Thorazine;others)
tricyclics fluphenazine (Permitil;Prolixin)
trimiprimine (Surmontil) haldoperidol (Haldol)
perphenazine (Trilafon)
ANTIHISTAMINES phenothiazines
astimizole piperacetazide (Quide)
brompheniramine prochloperazine (Compazine;others)
cetirizine promethazine (Phenergan;others)
cyproheptadine (Periactin) resperidone
diphenhydramine (Benadryl;others) thioridazine (Mellaril)
loratadine (Claritin) thiothixene
terfenadine
Comments / Any other Photosensitive Medication which you are currently taking:
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 PHOTOSENSITIVE MEDICATIONS
Please circle any medications that you are taking or recently have been taking
trifluperazine (Stelazine;others) Bitter orange peel (Citrus aurantium)
triflupromazine (Vesprin) Buttercup plant (Rannunculus species)
trimeprazine (Termaril) Carrot family
Celery (Apium graveolens)
CARDIAC MEDICATIONS Cow Parsnip (Heracleum lanatum)
ACE inhibitors (Vasotec) Dill (Anthium graveolens)
amiodarone (Cordarone) Fennel (Foeniculum vulgare)
diltiazem (Cardizem) Fig (Ficus carica)
disopyramide (Norpace) Goosefoot (Chenopodium species)
losartanlovastatin (Mevacor) Kella fruit (Ammi visnaga)
pravastatin (Pravachol) Lemon peel (Citrus limonia)
quinidine Lomatium (Lomatium dissectum)
sotalol Lovage root (Levisticum officinale)
simvastatin (Zocor) Parsley (Petroselinum sativum)
Psoralea seeds (Cullen corylifolia,
CHELATING AGENTS Psoralea corylifolia)
DIURETICS Queen Anne’s lace (Daucus carota)
acetazolamide (Diamox) Rue leaves (Ruta graveolens)
amiloride (Midamor) St John’s wort (Hypericum perforatum)
bendroflumethiazide (Naturetin;others) Yarrow plant (Achillea millefolium)
benzthiazide (Exna;others)
chlorothiazide (Diuril;others) HORMONAL
chlorthaldonecyclothiazide (Anhydron) estrogen replacementoral
furosemide (Lasix) contraceptives
hydroflumethiazide (Diucardin;others) other hormones
hydrochlorothiazid (eHydrodiuril;others)
methyclothiazide (Aquatensen,Enduron) HYPOGYCEMICS
metolazone (Diulo,Zaroxolyn) acetohexamide (Dymelor)
polythiazide (Renese) chloropropamide (Diabinase;Insulase)
quinethazone (Hydromox) glimipiride
trichlormethiazide (Metahydrin;others) glipizide
thiazides glybuide
tolazimide (Tolinase)
HERBAL MEDICINES tolbutamide (Orinase;others)
Additional plant families
Agrimony (Agrimonia eupatoria) SUNSCREENS - Containing
Angelica root and fruit (Angelica species) Benzophenones
Bergamot peel (Citrus bergamia) PABA (p-aminobenzoic acid)

I agree that the information listed above has been reviewed and presented with my clear understanding of what this
procedure involves.

Signed: ______________________________________________________ Date: _____________

(Patient or person legally authorized to consent for patient)

Witness: ________________________________________________________________
(To patient’s signature)

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