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

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):

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?

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