InMode Patient Intake

InMode Treatment

Please complete ALL sections to the best of your knowledge.
Patient Intake

Please complete ALL sections to the best of your knowledge.
Patient Name *

First NameLast Name
Patient DOB*

MonthDayYear
Age
Sex

FemaleMale
Emergency Contact Name

First NameLast Name
ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone*
Work Phone
Emergency Contact Phone
How did you hear about InMode Aesthetics?

ProviderSocial MediaInternet SearchOffice AdvertisingOther Referral SourceOther
What provider referred you?
Referral
What are your chief complaints about your skin and/or reasons for seeking INMODE Treatments?
Do you feel your skin is affected by the following (check all that apply):

Acne ScarringBroken CapillariesExcess HairCelluliteFrecklesFine LinesLarge PoresPhotoaging (Sun Damage)Pigmentation ChangesRednessRosaceaSkin Texture & ToneStretch MarksSun SpotsOther
Which areas do you feel are experiencing the issues listed above?

Around LipsCheeksChestChinForeheadHandsJawNoseNeckUnder EyesOther
Medical History
Please check if you are affected by, or have any of the following:

AcneAcute Porphyria (PCT)Auto-Immune DiseaseCold Sores/HerpesDermatitisDiabetesEczemaEpilepsyHIV/AIDSHirsutism (Excess Hair)Keloid ScarsImmunosuppresionLupus ErthematosusMalignant Lesions/MolesMelasma/Pigment ChangesMenopausePolycycstic Ovarian SyndromeRosaceaSensitive SkinSclerodermaSkin GraftThyroid DisorderVenous Issues/Blood ClotsOther
Do you have any other conditions not listed above, including any inflammatory or lympathic conditions? List below:
Do you have any of the following?

Birth Control ImplantDental ImplantsMetal Pins/ScrewsPacemaker/DefibrillatorPermanent MakeupSilicone ImplantsSkin GraftTattooVitiligo
Please list all medications you are currently taking (including herbal, over the counter, topical, oral, and supplemental):
Are you currently:

PregnantBreastfeedingTaking Birth ControlTaking Hormone ReplacementsTaking AntibioticsTaking Antiocoagulants/ASAExperiencing Active Cold Sores or Infection
Do you have any allergies to food or medications?

YesNo
If yes, please list allergies:
Do you have allergies/sensitivities to:

Aloe VeraLatexTopical Anesthetics
Have you recently had/used any of the following:

Anti-Wrinkle Injections/BotoxChemical/Glycolic PeelsDepilatory CreamDermal FillersLaser TreatmentSkin BleachingSurgical ProcedureThread LiftingWax/Hair Removal
If you marked any treatments above, please list treatment & last treatment date(s) below:
Have you ever had any minor or major sensitivities or reactions to any prior InMode or Laser treaments?

YesNo
If yes, please describe type of treatment used and describe the reaction you experienced:
Do you have an active sunburn or windburn in treatment area?

YesNo
Do you currently take/use any of the following photosensitive herbs/meds?

AccutaneBirth ControlGinko BilobaCitrus Essential OilsNaproxenSt. John's WortTricyclic AntibioticsOther
Tell us about your current skin care routine. Please include what products you are using.
What is your current hair removal system?

Depilatory CreamElectrolysisPluckingShavingWaxing
Do you smoke?

YesNo
If yes, how many packs per week?
Do you tan (including Self Tanners)?

YesNo
If yes, what is the frequency?
What is the frequency of your last UV exposure that was greater than 1 hour?
** I affirm the above information is accurate to my knowledge. I acknowledge that CELEBRATION OBSTETRICS & GYNECOLOGY Staff are not responsible for any errors that may occur as a result of any omissions or incorrect information on this form.
Patient Signature *

Clear
Patient Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

InMode Treatment

Patient Intake

Medical History