Patient Intake Form

Patient Intake Form
Name*

First Name and Middle Name or InitialLast Name
Date of Birth*

MonthDayYear
Date
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Language Occupation

PLEASE READ EACH SECTION CAREFULLY. YOU MAY REQUEST A COPY OF THIS FORM FOR YOUR OWN RECORDS

To the best of my knowledge, the information provided above is true and accurate. I agree to tell the staff of any changes to my health history or medications as they arise. I understand that information is necessary for your practice and will remain confidential. All efforts are routinely made to ensure privacy is upheld.

I, the undersigned, do hereby request and consent to an evaluation and treatment by Rêve et Réalize and its staff (“Practice”). I wish to rely on the Practice to exercise judgment for my best interest, the below-named patient, during the course of treatment. I will inform the Practice of any sensitive areas or adverse conditions that I may have had prior to, during or after treatment. I intend this consent to cover the entire course of treatment.

I understand that any questions I may have regarding the potential side effects, complications, treatment or treatment area may be directed to the attending Practice staff member during my evaluation and course of treatment.

I consent to photographs of before and after to demonstrate results in my chart, and will give separate permission for photographs published on social media, for educational purposes, conferences, or websites if desired.

I understand that the practice of medicine and surgery is not an exact science. I further understand and accept that fees are paid for performance of medical services only, and not a guaranteed result. I acknowledge by my signature below that although a good outcome is expected, and a reasonable effort has been made to establish realistic expectations, there cannot be any warranty, expressed or implied, as to the results that may be obtained.

I request and consent to be transported by Practice staff and/or emergency medical services to a hospital or emergency medical facility in the event of a medical emergency during the course of my treatment at the Practice.
Signature*

Clear
DateTime
Appointment
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