Snatched Physique LLC
NEW CLIENT FORM AND MEDICAL HISTORY
First & Last Name:
Birthdate:
/
Month
/
Day
Year
Date
Address:
City, State, Zip:
example@example.com
Cell Number:
Emergency Contact & Phone Number:
Email
example@example.com
How did you hear about us?
Would you like to be added to our email and/or text list to stay up to date on current Promotions and Coupons?
YES
NO
Do you have a history of or are you currently experiencing any of the following? Check all that apply...
Kidney/Urine Infections
Epilepsy
Diabetes
Hormone Replacement Therapy
Cancer
Contraceptive : Pill / IUD / Other
Autoimmune Disease
Currently Pregnant or Breastfeeding
Current Infection, Fever, or Disease
Cardiovascular Conditions : Thrombosis/Phlebitis/Hypotension/Hypertension/Heart Disease
Immunodeficiency Disorders
HIV/AIDS
Thyroid Problems
Skin Issues : Dermatitis/Light Sensitivity
Digestive Problems : Constipation/Bloating/Gallbladder/Stomach
Circulation Problems : Heart/Blood Pressure/Fluid Retention/Varicose Veins
Gynecological Conditions : Irregular Periods/PMT/Menopause
Nervous System Conditions : Migraines/Tension/Stress/Depression
Any Past Surgery : If YES, list below:
Other
List all medications, vitamins, and supplements that you are currently taking:
List any known allergies:
List any previous laser procedures:
Area(s) interested in treating:
Print Name
Print Name Signature
Date
/
Month
/
Day
Year
Date
STAFF INITIALS:
SW/AH
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