Medical Procedures Patient Intake Form

Name

First NameLast Name

Date of Birth

Date

Gender

Other

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address Line 2

State

Country

What procedure or service you're going to get?

Height

Weight

Are you pregnant or breastfeeding?

Family planning method :

Tobacco amount per day:

Are you drinking alcohol?

Are you under any medication for the last 6 months? If yes, please indicate and explain it below:

Are you taking any of the following medications?

Do you have any known allergies to food, cosmetics and drugs and medicine? If yes, please indicate and explain it below:

Do you have any medical conditions that the clinic should be aware of? If yes, please indicate and explain it below:

Do you have any of the following condition?

Do you have symptoms of COVID-19 for the past 7 days?

Have you had any type of surgery before? If so, please indicate.

Were you exposed to someone with COVID-19 for the past 14 days?

Have you been vaccinated for COVID-19?

How did you hear about us?

I understand that this procedure cannot guarantee 100% expeted results.

I understand that post-operative care are needed in order to fully achieve the goal. I confirm that it is my responsibility to follow the treatments and follow-ups after the procedure.

I permit the clinic to take photographs and videos of the procedure for educational purposes only.

I allow this clinic to use my photographs for "before and after results" for marketing and advertising purposes.

I hereby release this clinic and travel agency for any indemnification or hold them harmless agains physical damage, personal injury, or accidents that might happen during and after the procedure.

I confirm that all information I provided in this form is accurate and true.

Patient Signature

Date Signed

Date

Medical Procedures Patient Intake Form

Patient Information

Acknowledgment and Waiver