NEW PATIENT INTAKE FORM

How much water do you consume daily? *

How much caffeine do you consume daily? *

Do you currently have a sunburn/windburn or red face? *

Are you in the habit of using tanning booths or self tanner? *

Do you wear contact lenses or eye glasses? *

Do you have intolerance to heat or cold? *

Do you have any medical concerns that have not been covered in this form? *

Have you received any of the following procedures?*

{haveYou35} - Please Explain*

Have you used any of the following topical/oral medications?*

Current Medications (including birth control and over the counter): *

Current Herbal Supplements and Vitamins: *

Habits*

TobaccoAlcoholCaffeineNone of above

Frequency of tobacco use: *

# of years using tobacco: *

Date Last Used Tobacco *

Date

Frequency of Alcohol use: *

# of years using Alcohol: *

Date Last Used Alcohol:*

Date

Frequency of Caffeine use: *

# of years using Caffeine : *

Date Last Used Caffeine:*

Date

Allergies (food, latex, dairy, seafood, asprin, medications):*

YesNo

Explain:*

Please indicate services or areas for which you are interested in:*

Additional Comments:

Would you like to learn how to earn an extra $25.00 credit towards your next service?*

YESNO

I have freely and truthfully submitted my medical information. I have been given information regarding HIPPA. I understand it is my responsibility to report any updates or changes in my medical conditions to Classic Beauty Aesthetics & Wellness, LLC (dba Med Spa 31:25) employees or Health Care Provider prior to receiving any treatments or procedures.

Client Signature: *

Print Client Name: *

First NameLast Name

Date:*

Date

NEW PATIENT INTAKE FORM

Review of Systems