PATIENT INTAKE FORM

  • PATIENT INTAKE FORM

  • PATIENT INFORMATION

  • Date of Birth
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • MEDICAL HISTORY

  • Do you have any known allergies? (e.g., medications, latex, anesthesia, fish, etc
  • Do you have any of the following conditions?
  • Have you had any metal replacements added to your body. I.e. Hip, knee, pacemaker, etc
  • Are you currently taking any medications, including blood thinners, retinoids, or antibiotics?
  • Have you received any aesthetic treatments in the past 6 months (e.g., Botox, fillers, laser treatments, micro needling)?
  • What are your primary skin concerns? (check all that apply)
  • Have you used any retinol, glycolic acid, or other exfoliating treatments in the last 7 days?
  • Do you have a history of keloid scarring or poor wound healing?
  • Have you had any previous allergic reactions to aesthetic treatments or skincare?
  • Are you currently or is there a possibility that you might be pregnant?
  • How did you hear about us?*

  • INFORMED CONSENT & WAIVER
    I understand that  some     procedures may cause mild redness, swelling, or tenderness at the injection site. I acknowledge that individual results may vary and that multiple sessions may be required for optimal results. 

    I confirm that I have disclosed all relevant medical history and understand that failure to do so may increase the risk of adverse effects. I consent to receive the treatment and acknowledge that I have been informed of the risks, benefits, and expected outcomes.

  • Date
     / /

  • TREATMENT DECLINE DUE TO FISH ALLERGY
    Some treatments, such as salmon DNA, may contain ingredients derived from fish, which may cause allergic reactions in individuals with fish allergies. As patient safety is our top priority, we cannot proceed with these types of treatments for patients with a confirmed fish allergy.

    By signing below, I acknowledge that I have been informed about the risks associated with my allergy and understand that I am not eligible for the Nucleofill treatment. I confirm that I have discussed alternative treatment options with my provider.

  • Date
     / /

  • OFFICE USE ONLY Practitioner Notes:

  • Consultation Payment

  • Please select the type consultation you would like

  • My Products

    prevnext( X )
    Consultation Booking. Consultation fee for professional services including hair and scalp evaluation and medical weight management assessment. This appointment includes a comprehensive review of health history, current concerns, lifestyle factors, and treatment goals. During the consultation, a personalized plan may be developed with recommendations for appropriate services, therapies, or products based on the individual evaluation. The consultation fee covers the time and professional expertise provided during the visit and is required to reserve the appointment. Fees are non-refundable and apply to the consultation service only unless otherwise specified.
    Consultation Booking

    Consultation fee for professional services including hair and scalp evaluation and medical weight management assessment. This appointment includes a comprehensive review of health history, current concerns, lifestyle factors, and treatment goals. During the consultation, a personalized plan may be developed with recommendations for appropriate services, therapies, or products based on the individual evaluation.


    The consultation fee covers the time and professional expertise provided during the visit and is required to reserve the appointment. Fees are non-refundable and apply to the consultation service only unless otherwise specified.

    $125.00$125.00
      
    Total
    $0.00$0.00

    Payment Methods

    creditcard
    After submitting the form, you will be redirected to Apple Pay to complete the payment.
    After submitting the form, you will be redirected to Google Pay to complete the payment.
    After submitting the form, you will be redirected to Cash App Pay to complete the payment.
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