New Intake Form

New Intake Form

Patient information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information
May we send correspondence to your home address?

YesNo
Home Phone:
Cell Phone:*
May we leave a detailed message on your phone number?*

YesNo
E-mail*
example@example.com
May we contact you via email?*

YesNo
I want to opt out of receiving promotions

YesNo
Emergency Contact

First NameLast Name
Relationship
Where did you hear about us?*

Internet (Google, Website, Realself, Yelp - please, specify below)Social media (Instagram, Youtube, Facebook, Pinterest - please, specify below)Patient referral (please, provide name below)Doctor referral (please, provide name below)Other (Newsletter, Event, TV/Media - please, specify below)
Please specify your selection
Medical history
Do you take ANY medications, herbal supplements or topicals on a regular basis?*

YesNo
Please list
Do you have ANY allergies to medications, food, latex, animals, environments or other substances?*

YesNo
Please list
Do you have ANY autoimmune or chronic condition?*

YesNo
Please list
Are you experiencing any flu-like symptoms (fever, body aches, fatigue, sore throat, and etc) today?*

YesNo
Please list
Have you ever had surgery?*

YesNo
If so, when and what area?
Have you ever had: (mark all that apply)

Botox, Xeomin, DysportDermal FillerLaser
If so, when and what area?
Have you ever had problems associated with any previous procedures?

YesNo
If so, please specify
For our female patients
Are you pregnant?

YesNo
Are you breastfeeding?

YesNo
Westside Aesthetics does not give refunds on any products or services rendered. Your results may vary; therefore, we cannot and do not guarantee your patient satisfaction and/or expectation(s) for the services rendered.*
Your Initials
I have read and understand the above questions. By signing this document, I agree that the information contained herein is true to the best of my knowledge.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: