NEW INTAKE FORM

Todays Date

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NEW INTAKE FORM

RIVKIN WESTSIDE AESTHETICS
PATIENT INFORMATION
Patient Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
CONTACT INFORMATION
May we send correspondence to your home address?

Yes No
Home Phone *

Area Code Phone Number
Cell Phone *

Area Code Phone Number
May we leave a detailed message on your phone number?

Yes No
Patient E-Mail *
May we contact you via email?

Yes No
I want to opt out of receiving promotions:

Yes No
Emergency Contact *
Emergency Contact Phone Number *

Area Code Phone Number
WHERE DID YOU HEAR ABOUT US?
Google Website Yelp Social Media Patient Referral Doctor Referral
Please share the name of the patient who referred you.
Please share the name of the doctor who referred you.
Our doctors are often asked to be guests experts with local and national media. If the opportunity arose would you be interested in sharing your story?

Yes No
MEDICAL HISTORY
Do you take ANY medications, herbal supplements or topicals on a regular basis? *

Yes No
Please list:
Do you have ANY allergies to medications, food, latex, animals, environments or other substances? *

Yes No
Please list:
Have you ever had surgery? *

Yes No
If so when and what area?
Have you ever had: (mark all that apply)

Laser Botox, Dysport, Xeomin Dermal Filler
If so when and what area?
Have you ever had problems associated with any previous procedures? *

Yes No
If so please specify:
Are You Pregnant? *

Yes No
Are You Breastfeeding? *

Yes No
Westside Aesthetics does not give refunds on any products or services rendered. Your results may vary; therefore, we cannot and do not guarantee your patient satisfaction and/or expectation(s) for the services rendered.

I have read and understand the above questions. By signing this document, I agree that the information contained herein is true to the best of my knowledge.
Client Signature *

By signing you agree to the conditions stated above Clear
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