Medical History | Piel Spa

Module 1

Patient Information

Please confirm your details and complete a few additional items.

Takes about 5 minutes

Physical Address

Emergency Contact (optional)

Module 2

Reason for Visit & Health History

Tap each section below to open it.

Reason for Visit

Select one or more reasons that describe why you're consulting us today.

Other

Medical History

Select every condition that applies to you. If none apply, choose "None of the above" below.

Other Medical Condition

Blood Thinners

Have you taken any of these in the last 7–10 days?

Allergies

Do you have any of the following allergies?

Other Allergies

Facial / Head & Neck Surgeries

Have you had any of these?

General & Body Surgeries

Have you had any of these?

Other Surgical Procedure

Module 3

Previous Aesthetic Treatments

For each treatment below, answer Yes or No.

Other Aesthetic Treatment

Module 4

Skin Classification

This section is completed by clinical assessment. Select the single option that best matches your skin for each scale.

Fitzpatrick Skin Phototype

Select the one description that best matches how your skin reacts to sun exposure.

Skin Type

Select the one option that best describes your skin's general condition.

Compare each reference photo to your skin and select the single type that matches best.

Module 6

Health Screening for Weight Loss

These questions help us choose a safe treatment for you.

Habits & Goals (optional)

What weight would you like to reach?

How often do you exercise?

How often do you drink alcohol?

Module 5

Consent & Signature

Notice of Privacy Practices placeholder text.

I acknowledge and consent to the handling of my confidential medical information as described above. Required: I consent to clinical intake & record keeping. Optional: de-identified social media / educational marketing. I confirm that the medical history provided above is complete and accurate.

Full Name as Electronic Signature

Filled in with the name from Step 1 — correct it if needed.

Draw Your Signature Below