Cosmeceutical Assessment Form
This form only serves to better monitor your medication therapy and improve your health outcomes.
Referred By
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Last Name
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First Name
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Middle Initial
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Sex
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Race (optional)
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Date of Birth
MM
/
DD
/
YYYY
Address
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City
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State/Province
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Zip Code
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Provide shipping address if different than the address above
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Phone Number
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Alternate Phone Number
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Email Address
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Are you nursing, pregnant, or trying to become pregnant? (Women only)
Are you menopausal? (Women only)
Drug Allergies
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Food or Other Allergies
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List your current medications and/or health conditions
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Have you had any adverse reactions to products in the past?
Name the product and type of reactions
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Indicate your skin color on a scale from 1 - 10
very light skin
very dark skin
How would you describe your skin?
Main Concern(s) (specify concern & how long you've been concerned)
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Other Concerns
Pick all that applies
Required
On average, how many hours do you spend in the sun?
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Current Morning Daily Regimen
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Current Evening Daily Regimen
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How long have you been doing this regimen?
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What is the name of the products that you use?
If you know the ingredients in your products, please list them here too!
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Current Weekly Regimen
Names and ingredients
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How long have you been doing this regimen?
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Current Monthly Regimen
Names and ingredients
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How long have you been doing this regimen?
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Any additional concerns?
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Please email us a picture of yourself to drchauphan@pleasantcarepharmacy.com
Required
Gift Certificate Code (optional)
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Please read the following statements and approve below.
I have read or have had explained the information provided about the product(s) I am to receive. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the product(s) and ask that the product(s) be given to me or to the person named above for whom I am authorized to make this request. I absolve Pleasant Care Pharmacy and all persons connected with the pharmacy from any claims that may result from my strictly voluntary participation.
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