Patient Intake Form

Date*

Patient Name*

First NameLast Name

Address*

Street Address

CityState / Province

Postal / Zip Code

Email*

Phone Number*

Preferred method of communication from our office?*

TextPhone CallEmailOther

Date of Birth*

Age*

Sex*

FemaleMaleTransgenderOther

Marital Status

Occupation

Employer

Emergency Contact Name*

Relationship*

Emergency Contact Phone Number*

How did you hear about us?

Reason for consultation:*

Please describe your skin and skin concerns (please check all that apply)*

Other:

Are there any other treatments/conditions you are interested in hearing more about? (please check all that apply)

Other:

What is important to you when deciding on a skin treatment?

Do you have any specific skin conditions pertaining to your face and body? If yes, please specify. *

Do you experience ingrown hairs?

YesNo

Do you experience irritation from shaving?

YesNo

For unwanted hair, do you...? (please check all that apply)

What SPF sun protection do you use on your face? *

What SPF sun protection do you use on your body? *

Are you using Retin-A, Hydroquinone (bleaching cream), glycolic acid, Accutane, Differin Gel or any other medication that could cause sun sensitivity?*

YesNo

If yes, please specify:

Have you had any recent sun exposure in the past 4-6 weeks, including tanning beds, bronzing creams or spray tans?*

YesNo

If yes, please specify:

Please check all steps that apply to you in your daily skincare routine.*

What brand name(s) do you use in your skincare regimen? *

Are you happy with your current skincare regimen?*

YesNoUnsureI don't have one

Do you follow a restricted diet?*

YesNo

If yes, please explain:

Do you smoke cigarettes?*

YesNo

Do you drink alcohol?*

YesNo

If yes, how often?

Do you use drugs?*

YesNo

If yes, please explain:

Do you have regular sleep patterns?*

YesNo

If no, please explain:

Do you consume caffeinated products?*

YesNo

If yes, please explain:

Do you exercise regularly?*

YesNo

Do you have any allergies?*

YesNo

If yes, please specify:

Who is your primary care provider?

Do you have neurologic conditions?*

YesNo

If yes, please explain:

Do you have cardiovascular conditions?*

YesNo

If yes, please explain:

Do you have respiratory conditions?*

YesNo

If yes, please explain:

Do you have endocrine conditions?*

YesNo

If yes, please explain:

Do you have liver conditions?*

YesNo

If yes, please explain:

Do you have kidney conditions?*

YesNo

If yes, please explain:

Do you have autoimmune conditions?*

YesNo

If yes, please explain:

Do you have infectious conditions?*

YesNo

If yes, please explain:

Do you have coagulation conditions?*

YesNo

If yes, please explain:

Do you have hereditary conditions?*

YesNo

If yes, please explain:

Do you have connective tissue disorders?*

YesNo

If yes, please explain:

Do you have cancers?*

YesNo

If yes, please explain:

Do you have eye conditions?*

YesNo

If yes, please explain:

Do you have skin conditions?*

YesNo

If yes, please explain:

Do you have psychological conditions?*

YesNo

If yes, please explain:

Have you had surgery (including cosmetic)?*

YesNo

If yes, please explain:

Have you had any chronic illnesses in the past 5 years that are not listed above?*

YesNo

If yes, please explain:

Do you faint easily?*

YesNo

Do you scar easily?*

YesNo

Drug Therapy: Please list any prescribed or over the counter oral or topical medications including: allergy medications, acne treatments, pain medication, herbs & vitamins. If none, please write none. *

Pharmacy Name:

Pharmacy Town/State:

Have you ever seen a dermatologist?*

YesNo

If yes, please explain:

Have you ever had a chemical peel?*

YesNo

Last treatment date & area treated:

Have you ever had any laser or photofacial treatments?*

YesNo

Last treatment date & area treated:

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?*

YesNo

If yes, please describe:

Have you ever had neurotoxin injections such as Botox or Dysport?*

YesNo

Last treatment date & area treated:

Have you ever had Dermal Filler, Kybella, or Sculptra injections?*

YesNo

Last treatment date & area treated:

Do you have any permanent cosmetic tattoos?*

YesNo

Do you suffer from claustrophobia?*

YesNo

Do you wear contact lenses?*

YesNo

Do you ever get cold sores on mouth or genitalia?*

YesNo

Could you be pregnant?

YesNo

Are you breastfeeding?

YesNo

Are your menstrual cycles normal?

YesNo

Do you take birth control pills?

YesNo

Do you get Depo-Provera shots?

YesNo

If yes, when was your last treatment date?

Do you get menopausal/peri menopausal hormone replacement therapy?

YesNo

Do you have periodic acne flare-ups related to your cycle?

YesNo

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?

YesNo

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...

YesNo

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.

I have read and fully understand Empower MedSpa’s policies as outlined above and acknowledge that all of my questions regarding the policies have been answered to my satisfaction. By signing below, I agree that, by booking an appointment at Empower MedSpa I will be subject to the following policies.*

I consent that all information on this form was answered truthfully, and accurately.*

YesNo

Signature*

Date*

Date

Patient Intake Form

Skin Care

Social History

Medical History

Chronic or Current Conditions

For women only:

For waxing patients:

Empower MedSpa Policies

HIPAA Information and Consent