New Client Intake

New Client Intake

This information will help us provide you with the best treatments.
Name*

First NameLast Name
Age
Occupation
Gender
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person

First NameLast Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Relationship to the Patient

Medical / History Data
Have you had any recent surgeries or any other health conditions or concerns that we should know about?
Are you wearing any implantable medical devices or metal implants? If yes, what are these devices?
Are you currently taking any medications (including injectible fillers and botox)? If yes, please list them below:
Are you pregnant, breastfeed, or nursing? (Female)

YesNo
Authorization
- I confirm that all information given in this form is true, complete, and accurate.
- I released this organization for any responsibility in case of accident, illness, or injury.
- I acknowledge that no assurance was offered about the outcome.
Signature of the Patient*
Parent/Guardian Name

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Medical / History Data