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Patient Name
*
Mrs.
Mr.
Ms.
Ms
Name
Last Name
Suffix
Phone
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Address
*
Street Address
Greenacres
Please Select
Alabama
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California
Colorado
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District of Columbia
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33463
Civil Status
*
Single
Widowed
Long-Term Partnership
Married
Other
How did you hear about Élévatione Spa & Beauty?
*
Advertisement
Facebook
Friend or Family
Google
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Canopy- Hilton Hotel
Occupation
*
MEDICAL AND SKINCARE:
Your safety is our top priority, please answer all questions truthfully for your own well-being.
What would you like to achieve from today’s visit?
*
Expert Care
Relaxation & Rejuvenate
Cleanse Your Skin
Reduce Stress
Prevent Aging
Treat Acne & Blemishes
Other
What are your current skin concerns? Dark spots
*
Blackheads
Hormonal Acne
Broken Capillaries
Puffiness and Dark Circles
Dull and Dry Skin
Forehead Wrinkles
Dark Spots
Pigmentation and Discoloration
Large Pores
Lifting and Firming
Combination and Oily Skin
Rough Texture
Fine Lines
Under-Eye Wrinkles
Other
What are your long-term skin care goals?
*
Address Fine Lines & Wrinkles
Prevent Wrinkles
Skin Problems (Acne, Uneven Tone or Texture)
Dark Circles
Age Spots
Tone & Texture
List the skin care products you currently ; seen improvements?
*
None
In the past three months, have you undergone any intervention treatments (such as plastic surgery, laser, fillers, or Botox)? If yes, please describe the purpose and course of treatment.
*
None
Do you suffer from allergies? If yes, please list.
*
None
Are you currently on any prescribed medications, supplements, or vitamins? If yes, please list.
*
Do you have any history of cold sores or fever blisters? If yes, please describe.
*
No
Have you ever been diagnosed with cancer in the past, or are you currently undergoing treatment for cancer?
*
Please Select
Yes
No
Please note that certain technological treatments at our medical spa may not be suitable for patients with cancer.
Have you undergone any surgery or been under general anesthesia in the past 6 months?
*
Yes
No
Do you drink alcohol?
*
Yes
No
On Occasion
Are you currently pregnant or breastfeeding?
*
Yes
No
Is there anything else we should know?
*
Booking Type
*
Body Sculpting Fat Reducation
Hydra-Glow Experience
Botox/ Fillers/ Taja Drip
Non-Surgical Facelift
Led+ Cryo Facial
Skin Tightening Facial
Add Ons
prev
next
( X )
Collagen Anti-Wrinkle Booster
$39.99
$
39.99
Vitamin C Booster
$39.99
$
39.99
Anti-Aging Neck & Décolletage Treatment
$49.99
$
49.99
Extractions
$24.99
$
24.99
Product Name
Free
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Signature:
*
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Submit
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