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Home
Treatments
Subscribe
New Clients
Blog
- Blog
- Social Posts
Contact
Instagram
Facebook

New Client? We Can’t Wait To Treat You!

Thank you for choosing MIVAS aesthetics! Prior to your first appointment, please fill out the form below to help us better understand your current skin care regimen, history, and concerns.

Step 1 of 3

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Name(Required)

First Last

Phone(Required)

Email(Required)

Date(Required)

MM slash DD slash YYYY

Current Skin Care Regimen

Cleanser?

Toner?

Cream?

Other?

Facial Surgery

Had laser resurfacing or facial plastic surgery in the past 3 months?(Required)

Yes

No

When?(Required)

Planning to have facial resurfacing?(Required)

Yes

No

When?(Required)

Planning to have blepharoplasty?(Required)

Yes

No

When?(Required)

Planning to have other facial plastic surgery?(Required)

Yes

No

When?(Required)

History

Allergic to any of the following?(Required)

Aspirin

Latex

Hydrogen Peroxide

Clindamycin

Salicylic Acid

Fragrances

Alpha Hydroxy Acids

Beta Hydroxy Acids

Retin-A

Talc

No allergies to any of the above

Any other allergies? Please specify:

Currently taking antioxidant supplements?(Required)

Yes

No

Currently using Retin-A?(Required)

Yes

No

If yes, what do you use it for?(Required)

Acne

Fine lines

Has irritation, sensitivity, or flaking occurred from Retin-A use?(Required)

Yes

No

Currently using the acne drug Accutane?(Required)

Yes

No

Have you used Accutane in the past?(Required)

Yes

No

If yes, how long ago?(Required)

Are you exercising regularly?(Required)

Yes

No

Are you a smoker?(Required)

Yes

No

Oil Secretion

Do you experience excessive oiliness throughout the day?(Required)

Yes

No

Do you experience frequent breakouts?(Required)

Yes

No

Moisture Hydration

Daily consumption of water?(Required)

1-2 Cups

3-5 Cups

6+ Cups

Sunscreen /Sunblock usage?(Required)

1-2 Cups

3-5 Cups

6+ Cups

Moisture products?(Required)

Yes

No

Other Concerns

Experience irritation from shaving?(Required)

Yes

No

Experience ingrown hairs?(Required)

Yes

No

Experience folliculitis?(Required)

Yes

No

Treatments Performed By:

Melissa Vasquez, MS, CRNA
Danielle Panza, PA-C
Jordan Lasky, PA-C
Michael Vasquez, MD

Book an Appointment

Find Us Here:

4927 Main St, Suite 400
Amherst, NY 14226
(Inside the Venous Institute)

Phone: 716-877-7000
Fax: 716-322-1164

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