CLIENT INFORMATION FORM

Name

First NameLast Name

Age

Number Only

Birthday

Date

Gender

Phone Number

Occupation

Email

example@example.com

ADDRESS

STREET,BLDG,BRGY

CITY

How did you know about ETHOS SKIN AESTHETICS?

Patient Status

Appointment

In which Non-surgical procedure you are interested in?

FACIAL

FNT/ Microneedling Treatments

Derma Services

IV Drip/ Push

MD Peel Treatments

Melasma Treatments

Around the Eye Treatments

Hair And scalp Treatments

Skin Booster/ Biostimulator

Acne Scar Treatments

Are you currently under a physician's care?

If Yes, since when? and Why?

Are you routinely taking any medication, herbal supplements, vitamins, or substances?

If Yes, please list.

Please choose if you have allergies on the following

If you have allergies, please specify

Have you taken aspirin or any other anti-inflammatory drugs in the past 14 days?

Are you pregnant or suspect you may be?

Have you ever been treated for or been told you might have heart disease?

Have you ever had any of this?Please choose if you have allergies on the following

Do you have any disease, condition, or problem not listed? Please list down.

Have you ever had previous treatments such as

Please specify area, previous reactions or concerns related.

LIABILITY RELEASE ACKNOWLEDGEMENT AND WAIVER:
The undersigned understands, acknowledges and agrees that (i) l am aware that the facilities and services offered by Ethos Medispa Operations referred to as EMO involve risks; (ii) the information I have provided above is accurate and complete regarding my current health status; (iii) I am seeking aesthetic medicine treatments of my own free will; and (iv) assume all risks associated therewith. In consideration of my being permitted to use these facilities and services, on behalf of myself, my heirs and my assigns. I hereby release and discharge the entity that operates Ethos Medispa Operations (the Owner), and all of their affiliates, subsidiaries, employees, directors, officers, insurers, agents, landlords, representatives, successors and assigns from any and all claims, causes of actions, suits, damages, judgements, executions or demands, including court costs and reasonable attorney fees arising out of or relating to my aesthetic treatment, including but not limited to those resulting from bodily injury, theft, loSs of, or damage to property of mine.

Client Signature

SIGN HERE

PRIVACY NOTICE

At Ethos Skin Aesthetics, we respect your privacy and are committed to protecting your personal information. We use the details you provide only to manage your account and to deliver the treatments, products, and services you request from us. We may also contact you occasionally to update you about your progress, share clinic updates, and inform you about services or offers that may interest you. Your information will be handled with care and kept confidential at all times.

CLIENT'S RECORD