Patient Name:Address:

Mailing Address (if different): Home: Cell: Work: Email Address:How did you hear about us?

Medical AestheticData Form

1757 Rock Quarry RoadStockbridge, GA 30281

T (770) 506-9123 F (770) 506-1915

SchillingMedicalSpa.com

Patient ID: (FOR OFFICE USE) Today’s Date:

DOB: Social Security #:

EMERGENCY CONTACT Name:EMERGENCY CONTACT Phone:Relationship:

Employer:Occupation:

If a friend, name?

check preferredcontact number

a practice by John P. Schilling, MD

Obstetrics Gynecology Cosmetic Surgery Medical Aesthetics

Facials - Facial ServicesChemical PeelsHome Skin Care ProductsHyper-Pigmentation Rosacea

MicrodermabrasionBotox® Dysport®

Juvéderm® Radiesse® Sculptra®

Laser Stretchmark ReductionLaser Skin Tightening/Anti-Aging

Please tell us what you would like more information about:Laser Hair ReductionLaser Vein TreatmentWeight-LossSmartlipo® & LiposuctionLipo-Abdominoplasty (Tummy Tuck)

Facial Fat GraftingButtocks EnhancementBreast Augmentation

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Breast-feedingArthritisAnemiaAsthmaBlood Pressure

CancerChronic PainDiabetesDepressionEdema

EpilepsyFatigueFibromyalgiaHeart DiseaseHIV / Aids

InsomniaNumbnessSinus ProblemsSmokerSpinal ProblemsVaricose Veins

Please check all that apply:

List ANY operation, surgery, or serious illness that have required hospitalization:Month/ Year Operation or Illness Complications (any)?

Have you ever had a cold sore or fever blister? NO YESAre you sensitive to LATEX? NO YESAre you currently pregnant? NO YESAre you attempting pregnancy? NO YESDo you wear contacts or eyeglasses? NO YES, Specify:ARE YOU CURRENTLY USING ANY ORAL MEDICATIONS? NO YES, Specify:ARE YOU CURRENTLY USING ANY TOPICAL MEDICATIONS? NO YES, Specify:Do you use birth control pills? NO YES, Specify:Do you have any allergies? NO YES, Specify:

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Have you ever taken Accutane? NO Yes, When Dosage Amt of timeHave you used Tretinoin (Retin-A)? NO Yes, Dosage (%)

Have you ever had any of the following procedures? Please give dates and any important details.

Botox/DysportRestylane/Radiesse/Other filler? SculptraComedone (blackheads) Extraction

Laser Chemical PeelsFacial Surgeries Number of Facials in last 12 months

Even color ToneSkin PigmentationAcneSkin Hydration

Lines / WrinklesSkin ElasticitySkin textureAcne Scars

Skin Disorder (list)Other Areas of Concern:Current skin care products used:

Areas of Concern (Please check all that apply):

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Please list any previous LASER or LIGHT-BASED hair reduction/removal treaments you have received:

Area(s) Treated Dates of Treatment Results/Comments (any sensitivity?)Type of Device Used

Other Hair Removal History:

Are you currently using any of the following tanning methods? (If so, please list last date used.)

Waxing:Tweezing:Electrolysis:Bleaching:Shaving:Other:

How often? Last time (date): List complications or sensitivity (if any):

Tanning Beds Outdoor Tanning

Airbrush TanningSunless Tan Lotions

Last time (date): Last time (date):

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I have listed all known medical/physical conditions, if there are any changes in the future, I will inform my PROVIDER at Schilling Healthcare Ent., PC of any changes. I agree to pay for all services at time they are rendered.

I understand that when scheduling an appointment I am required to reserve the appointment with a Credit Card or Gift Card number and a 24 hour notice is required to avoid paying missed appointment fees. A $30 fee will be charged for all returned checks.

I acknowledge by my signature below that I have read and understand the above statements and give my permission to receive this and any further treat-ments at Schilling Healthcare Ent., PC. I confirm to the best of my knowledge that the answers I have given on both pages, are correct and, that I have not withheld any information that may be relevant to my treatment.

Signature Date today (please add additional date if information is updated)

offIce uSe onLY:Date ENTERED: Initials: Date UPDATED: Initials:Date UPDATED: Initials: Date UPDATED: Initials:

Important Information for: Microdermabrasion, Facials, Chemical Peels, Injectables, Waxing, Laser or Light-Based Treatments

a practice by John P. Schilling, MD

Obstetrics Gynecology Cosmetic Surgery Medical Aesthetics

We would like to sincerely thank you for choosing our practice. Our goal is to de-velop a trusting relationship with you and provide excellent care and services to keep you healthy. We even offer some extra services to keep you looking as good as you feel.

Our doctors are dedicated to keep up with the latest training, techniques and prac-tices on complex female health issues. You can feel confident they will listen to you and understand your personal needs.

Our practice is unique because we offer obstetrical and gynecological services, medi-cal aesthetic services, and cosmetic surgery.

Now that you have your appointment scheduled, we just wanted to let you know the other services we offer and would love for you to join us on social media to stay con-nected, hear the latest news, and even get special offers! Also, check out our quar-terly newsletters full of fun and informative information.

Facials - Facial ServicesChemical PeelsHome Skin Care ProductsHyper-Pigmentation RosaceaMicrodermabrasionBotox® Dysport®

Juvéderm® Radiesse® Sculptra®

Laser Stretchmark Reduction

Laser Skin Tightening/Anti-AgingLaser Hair ReductionLaser Vein TreatmentWeight-LossSmartlipo® & LiposuctionLipo-Abdominoplasty (Tummy Tuck)Facial Fat GraftingButtocks EnhancementBreast Augmentation

Please tell us what you would like more information about:

1757 Rock Quarry RoadStockbridge, GA 30281

Women’s Center (770) 474-7151Weight-Loss (770) 474-7151 Cosmetic Surgery Center (770) 506-9123Medical Aesthetics (770) 506-9123

Address:

Phone:

John P. Schilling, MD, FACOGTamika L. Sea, MDTope K. Olubuyide, MD

Website: SchillingMedicalSpa.comSchillingWomensCenter.com

Email: talktous@schillingmedicalspa.com

Social Media: facebook.com/johnschillingmd@drjohnschilling

Online Newsletter: issuu.com/schillinghealthcare