• Patient Intake Form

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Preferred method of communication from our office?*
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex*
  • Format: (000) 000-0000.
  • How did you hear about us?*
  • Please describe your skin and skin concerns (please check all that apply)*
  • Are there any other treatments/conditions you are interested in hearing more about? (please check all that apply)

  • Skin Care

  • Do you experience ingrown hairs?
  • Do you experience irritation from shaving?
  • For unwanted hair, do you...? (please check all that apply)
  • Are you using Retin-A, Hydroquinone (bleaching cream), glycolic acid, Accutane, Differin Gel or any other medication that could cause sun sensitivity?*
  • Have you had any recent sun exposure in the past 4-6 weeks, including tanning beds, bronzing creams or spray tans?*
  • Please check all steps that apply to you in your daily skincare routine.*
  • Are you happy with your current skincare regimen?*

  • Social History

  • Do you follow a restricted diet?*
  • Do you smoke cigarettes?*
  • Do you drink alcohol?*
  • Do you use drugs?*
  • Do you have regular sleep patterns?*
  • Do you consume caffeinated products?*
  • Do you exercise regularly?*

  • Medical History

    Please fill out as completely as you are able. All information will be held in strict confidence.
  • Do you have any allergies?*

  • Chronic or Current Conditions

  • Do you have neurologic conditions?*
  • Do you have cardiovascular conditions?*
  • Do you have respiratory conditions?*
  • Do you have endocrine conditions?*
  • Do you have liver conditions?*
  • Do you have kidney conditions?*
  • Do you have autoimmune conditions?*
  • Do you have infectious conditions?*
  • Do you have coagulation conditions?*
  • Do you have hereditary conditions?*
  • Do you have connective tissue disorders?*
  • Do you have cancers?*
  • Do you have eye conditions?*
  • Do you have skin conditions?*
  • Do you have psychological conditions?*
  • Have you had surgery (including cosmetic)?*
  • Have you had any chronic illnesses in the past 5 years that are not listed above?*
  • Do you faint easily?*
  • Do you scar easily?*
  • Have you ever seen a dermatologist?*
  • Have you ever had a chemical peel?*
  • Have you ever had any laser or photofacial treatments?*
  • Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin), keloid scars, or marks/scars from physical trauma, chicken pox, or acne?*
  • Have you ever had neurotoxin injections such as Botox or Dysport?*
  • Have you ever had Dermal Filler, Kybella, or Sculptra injections?*
  • Do you have any permanent cosmetic tattoos?*
  • Do you suffer from claustrophobia?*
  • Do you wear contact lenses?*
  • Do you ever get cold sores on mouth or genitalia?*

  • For weight-loss patients only:

    Specific to Empowered Health LLC.
  • Are you currently on a GLP-1 medication?
  • Have you ever taken a GLP-1 medication in the past?
  • Have you ever experienced any side effects from your medication?

  • For women only:

  • Could you be pregnant?
  • Are you breastfeeding?
  • Are your menstrual cycles normal?
  • Do you take birth control pills?
  • Do you get Depo-Provera shots?
  • Do you get menopausal/peri menopausal hormone replacement therapy?
  • Do you have periodic acne flare-ups related to your cycle?

  • For waxing patients:

  • Please indicate whether any of the following apply to you? (please check all that apply)
  • Do you have any piercings on the area being waxed today?
  • I understand that waxing can cause irritation, inflammation, and in some cases a rash. I confirm that the above information is true to best of my knowledge and belief. I hereby give my consent to proceed with waxing...

  • Empower MedSpa Policies

    Please read all policies in full.

  • Gift Cards

    Empower Med Spa gift cards make an ideal gift for any occasion and are available in any dollar amount.  The gift cards may be purchased online at www.empowermedspa.com, at the clinic, or by calling 802 528 2738. Gift cards are transferable, but non-refundable. Gift cards are redeemable for products and services. Empower MedSpa cannot assume responsibility for lost or stolen gift cards. A physical gift card must be presented at checkout. This could be an actual card or an email for gift cards purchased online. 

    Refund Policy

    At Empower MedSpa, it is our mission to provide you with the highest quality of skin and body care products with your services! In the event you purchase any of our skin or spa products for home use and find them to be defective, we will exchange the products within 15 days of purchase, provided a receipt and an in-store credit will be applied to your account. Any unopened product may be exchanged for an in-store credit within 15 days of being purchased. While we strive to make our clients as happy as possible, all services and package sales are final.

    A 25% deposit will be required when booking any quoted services. A deposit cannot be refunded but can be transferred to another spa service or in-store credit.

    Appointment Reservations

    We do require a valid debit/credit card be kept on file to reserve all appointments that are booked. We follow a strict 24-hour cancellation policy. If a scheduled appointment is not canceled within 24 hours or a patient is a no call no show, you will be charged the appropriate fee as outlined below.

    Cancellation Policy

    We understand that there are times when you must miss an appointment due to emergencies, health or obligations for work or family. However, when you do not call to cancel an appointment within 24 hours or fail to show up for your scheduled appointment all together, you may be preventing another patient from getting a much-needed service and are limiting the success of your provider. Our team values our patients, and we work hard to provide exceptional care. We only hope for the same respect in return.

    If an appointment is not cancelled at least 24 hours in advance you will be charged accordingly:

    Waxing, Facial & Massage Services, if a spa service is cancelled within 24 hours of your scheduled appointment, or you are a no-call/no-show, the cost of your service will be due in full, at a minimum of $55.  

    Medical, Emsculpt & Laser Services, if a medical service is cancelled within 24 hours of your scheduled appointment, or you are a no-call/no-show, the cost of your service will be due in full, at a minimum of $250.  

    All accrued fees must be paid in full before a patient can rebook an appointment at Empower MedSpa.

    In the event a patient has accrued four (4) or more documented “no-shows” and/or “same-day cancellations,” the patient may lose the ability to book appointments with us for one (1) full year. 

    Late Arrivals

    In the event of a late arrival, we will attempt to accommodate your needs.  However, in consideration of other guests’ time and schedule, Empower MedSpa may not be able to extend your appointment. Late arrivals may very well limit the time of your treatment. Treatments are to begin and end as scheduled and the full value of the service will be charged regardless of arrival time. 

  • HIPAA Information and Consent

    Please visit empowermedspa.com > home > HIPAA policy and read in full before signing this document. Thank you!
  • I consent that all information on this form was answered truthfully, and accurately.*
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: