Personalized Care ♟ Aesthetics
Let's get to know you...in private.
Patient Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
DOB
*
-
Month
-
Day
Year
Date Picker Icon
Sex assigned at birth
Male
Female
Patient E-Mail
*
example@example.com
Address of concierge visit:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
We want to put a face to your name. Please upload the front and back of your government-issued ID here:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Appointment
What are your main aesthetic goals?
Reduce wrinkles
Improve skin texture
Enhance volume
Improve tone & discoloration
Please check all that apply. I am interested in the following treatments:
*
Botox/Wrinkle Reduction
Dermal Fillers
Microneedling (+/- PRP)
Thread Lifts
Chemical Peels
Pigmentation Correction or treatment for spots, scarring or other skin irregularities
Lasers or Electrolysis (Tattoo Removal, and/or Laser Hair Removal)
Treatment for cellulite, varicose veins, and stretch marks
Body Shaping Treatments (Coolsculpting, Emsculpt)
Scar Treatment and Reduction
A cosmetic or reconstructive surgical consultation
I'm not sure and need help figuring this part out.
Other
Are you currently pregnant?
*
Yes
No
Not Applicable
Are you currently breastfeeding?
Yes
No
Not Applicable
Medical History
We care about you...
Have you ever had (Please check all that apply)
Anemia
Asthma
Arthritis
Cancer
Gout
Diabetes
Emotional Disorder
Epilepsy Seizures
Fainting Spells
Gallstones
Heart Disease
Heart Attack
Rheumatic Fever
High Blood Pressure
Digestive Problems
Ulcerative Colitis
Ulcer Disease
Hepatitis
Kidney Disease
Liver Disease
Sleep Apnea
Use a C-PAP machine
Thyroid Problems
Tuberculosis
Venereal Disease
Neurological Disorders
Bleeding Disorders
Lung Disease
Emphysema
Other
Do you have any allergies?
*
Yes
No
Please list your allergies:
Do you take any medications?
Yes
No
Please list your Current Medications:
Do you have a history of surgical procedures?
Yes
No
Please list surgical procedures & dates of each:
Healthy & Unhealthy Habits
No judgements, offering improvements upon request...
Exercise
Never
1-2 days/week
3-4 days/week
5+ days/week
Eating habits/following a diet
I have a loose diet
I have a strict diet
I eat generally healthy, but I could make improvements
I don't have a diet plan
Alcohol consumption
I don't drink
I am a social drinker (less than 5 drinks/week)
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
Do you smoke?
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Do you vape?
Yes
No
Are there any other elements or substances in your routine?
Caffeine
Marijuana
Magic Mushrooms
Cocaine
MDMA and/or 2CB
LSD
Methamphetamine
Other
CHECKMATE HEALTH AUTHORIZATION TO GIVE MEDICAL CARE – CONSENT TO TREATMENT: I hereby voluntarily consent to treatment and care from all medical personnel contracted with Checkmate Health. I further consent to the performance of any diagnostic procedures, examinations, laboratory tests and rendering of medical treatment by Checkmate Health Strategies’ medical Providers and staff, as is necessary in the medical staff’s judgment. I understand that this consent will be valid and remain in effect as long as I am a patient at the clinic.
*
Additional fees may apply for travel, emergency or same-day services, and any add-ons or additional treatments requested at the time of service. All fees will be communicated prior to service when possible.
prev
next
( X )
Deposit (Aesthetic Enhancements)
Non-Refundable. Pay remainder at time of booking.
$
295.00
Quantity
1
2
3
4
5
6
7
8
9
10
Submission Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: