Mobile Medtox Client Intake Medical Form

Personal Profile and Client Medical Intake Form
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender

MaleFemaleOther
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
How did you hear about us?*

GoogleFacebookInstagramYouTubeOnline AdsReferralOther
What part of your body do you want services performed?
What services did you want to get today?

Neurotoxin / BotoxFillersWeight Management - Semaglutide (Ozempic similar) or Tirzepatide (Monjaro similar)Fat Dissolving - Under Neck, Belly Fat, Thighs, Side Saddles, ArmsPRPLaser TreatmentMesotherapy
Medical Condition
Have you had any of these services before?*

Botox/NeurotoxinsFillersFat Dissolving InjectionsWeight Loss/Weight Management InjectionsPRP TherapiesNone
When was the date of your last treatment?

MonthDayYear
Date
Are you pregnant?*

YesNo
Are you breastfeeding?*

YesNo
Do you exercise regularly?*

YesNo
Are you currently taking any medications ? If yes, please list all of them below and what they were prescribed for.*
Do you have any allergies? If yes, please list all of them below.*

Do you have any of the following?*

	Yes	No	Remarks
Liver disease
Cardiovascular disease
Kidney disease
Skin disease
Thyroid glad problems
Gastrointestinal problems
Cancer
Immuno-compromised
Photosensitivity to sun
Epilepsy
Diabetes
Underoing hormonal therapy
HIV

Do you feel any pain on any part of your body? If yes, which part?*
Acknowledgment
I understand that this procedure cannot guarantee 100% expected results.I understand that several treatments might be needed to achieve good results.I allow Mobile Medtox to take photographs of my before and after results as proof of the treatment, case studies, advertising and marketing.I acknowledge that I have been informed of the difference between FDA approved and non FDA approved products. I approve the use of these products in my session.I acknowledge that I have been informed about the Off-Label status of Dermal Fillers, Neurotoxins and Deoxycholic Acids and understand and accepts its uses.
Signature
Date Signed*

MonthDayYear
Date
Certifications
Choose all you certify to be accurate*

I certify that the preceding medical and personal history statements are true and correct and am aware that I am responsible for informing the doctor or injector of my current medical health conditions and to update my information as it changes.Before and after treatment instructions have been discussed with me. The procedure, potential benefits and risks, and the alternative treatment options have been explained to my satisfaction.I certify that I understand the potential benefits and risks associated with the product being used and its FDA approval or non approval status for my procedure and I willingly consent to its use.
Signature
Signature*

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Date*

MonthDayYear
Date
Liability Waiver
I acknowledge that this activity may result in personal injury or medical complications. I hereby release Mobile Medtox, its affiliates, injectors, successors, or assigns from any current or future liabilities or claims, including but not limited to medical fees and personal injury. Additionally, I authorize Mobile Medtox to make medical decisions on my behalf if needed or if an emergency contact person cannot be reached.
Signature
Your Signature*

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Date Signed*

MonthDayYear
Date
Should be Empty:

Patient Information

Medical Condition

Acknowledgment

Certifications

Liability Waiver