Aesthetics Initial Consultation Form
All treatments are patient specific and require a care plan be formed with you and our nurse practitioner. Please allow up to 48 hours business hours for the nurse practitioner to reach out and set up an appointment with you after this form has been submitted.
I understand that this form is HIPPA compliant and will only be used for the purpose of documentation in my Athena electronic health record (EHR) and for review during any telehealth or phone consultations. This information will not be shared with anyone outside of my healthcare team unless a release of information form has been completed and signed granting permission.
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Yes
I understand that I must reside in NC to become an established patient undergoing treatment.
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Yes
I understand that Coastal Wellness NC has the right to recommend against treatment, as well as refuse to perform treatment, based upon their assessment of my responses if there are any medical concerns and/or contraindications.
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Yes
Required Demographic Information for your Athena Health Chart
Legal Name
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First Name
Last Name
Preferred Nickname, if applicable:
Anatomical Sex
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Male
Female
Gender Identification
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Male
Female
Transgender Male
Transgender Female
Non-Binary
Preferred Pronouns:
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He/Him/His
She/Her/Hers
They/Them/Theirs
Age:
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Date of Birth
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 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
(North Carolina) Physical Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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Preferred Language:
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Race:
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Caucasian
African American
American Indian or Alaskan Native
Asian
Native Hawaiian or other Pacific Islander
Ethnicity:
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Hispanic or Latino
Not Hispanic or Latino
Marital Status:
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Single
Married
Partner
Separated
Divorced
Widowed
Emergency Contact:
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First Name
Last Name
Emergency Contact's Phone Number:
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Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about Coastal Wellness NC?
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General Medical Information To Be Reviewed and Verified During Your Visit
Please provide a brief description of your current health and wellness goals:
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Which treatments are you interested in learning about/receiving? (can choose more than one)
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Morpheus8 (face/neck -- rejuvenation, smoothing, and tightening with deep RF treatment)
Morpheus8 (body -- fat burning, toning, and tightening with deep RF treatment)
FormaV (vaginal -- internal/external options -- improve blood flow, muscle tone, and appearance)
VTone (vaginal -- internal -- improve bladder incontinence, leaking, and pelvic floor strength)
Tone (large muscle groups -- tighten, condition and tone with electrical muscle stimulation)
I am not quite sure, but I want to learn about how you can help me feel better!!
Do you know what micro-needling and fractional radiofrequency (RF) is?
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Yes
No
I have heard about it, but I am not sure what it is
Do you know what electrical muscle stimulation (EMS) is?
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Yes
No
I have heard about it, but I am not sure what it is
Have you ever had any type of facial, body, or vaginal treatments performed previously?
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Yes
No
If you have had treatments previously, please list them below:
Have you ever had any type of facial, body, or vaginal cosmetic surgeries previously?
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Yes
No
If you have had cosmetic surgeries previously, please list them below:
Do you have a primary care provider? (Includes NPs and PAs)
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Yes
No
Primary Care Provider Name (if applicable):
Code Status (documentation required in EHR for all patients receiving treatments) :
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Full Code (if my heart stops, try to bring me back by all means necessary)
Do Not Resuscitate (if my heart stops, do not perform CPR, defibrillation or give medications)
I do not know my code status.. can you explain this further during my visit?
Height:
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Weight:
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BMI Calculator (duplicate information, but is a necessary calculation)
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Please list ALL allergies that you are aware of:
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Please list ALL medical conditions you have been diagnosed with:
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Have you been diagnosed with diabetes or pre-diabetes?
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Yes
No
Unsure; I have not seen my primary doctor within the past year or had lab work done
Please list ALL medications with dosages and/or supplements you are currently taking:
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Have you taken the medication Accutane within the past 6 months?
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Yes
No
Do you take any blood thinners (Xarelto, Eliquis, Pradaxa, Coumadin, Low-Dose Aspirin)?
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Yes
No
If yes to blood thinners; which blood thinner do you take?
Please list any general surgical procedures you have had previously:
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Do you have any surgical implants (plates, rods, screws, dermal piercings, silicone implants)?
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Yes
No
If yes to surgical implants; please specify the type of implant and the location:
Do you have an active electrical implant/device in any region of the body, including pacemaker/internal defibrillator, cochlear implants, nerve stimulators, and blood glucose monitoring devices?
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Yes
No
Do you have current or history of skin cancer, genital area cancer, or current condition of any other type of cancer, or pre-malignant moles?
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Yes
No
Do you have history of skin disorders, such as keloids, abnormal wound healing, or very dry and fragile skin?
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Yes
No
Do you have any tattoos or permanent makeup in the area that you are seeking treatment?
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Yes
No
Gynecologic History To Be Reviewed and Verified During Your Visit
Do you have an OB-GYN provider? (Includes NPs and PAs)
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Yes
No
Not Applicable (male anatomy)
OB-GYN Provider Name (if applicable):
Have you had a hysterectomy (removal of uterus)?
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Yes
No
Not Applicable (male anatomy)
Are you still having periods?
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Yes
No
Not Applicable (male anatomy)
If still having periods; when was your last period?
Are you pregnant or planning to become pregnant?
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Yes
No
Not Applicable (I have had a hysterectomy)
Not Applicable (male anatomy)
Do you have an intrauterine device (IUD)?
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Yes
No
Not Applicable (male anatomy)
When was your last pelvic exam? (Answer required for Vtone and FormaV)
When was your last pap smear, and was it normal? (Answer required for Vtone and FormaV)
Have you ever been diagnosed with uterine, bladder or bowel prolapse?
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Yes
No
Have you ever been diagnosed with a cystocele or rectocele?
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Yes
No
Have you had vaginal or pelvic surgery within the past 12 months?
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Yes
No
Not Applicable (male anatomy)
Have you experienced incontinence/stress incontinence with aging and/or being post-partum?
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Yes
No
I am not sure, but I sometimes pee when I sneeze, laugh or cough
Social Information To Be Reviewed and Verified During Your Visit
Are you employed currently?
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Yes
No
I am retired
I am disabled
Self-employed
If working, what type of work do you do?
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Are you currently or have you ever been a smoker? (Includes vaping)
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Never smoker
Former smoker
Current smoker
Trying to quit
Are you in recovery from substance use and/or alcohol use disorder?
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Yes
No
Do you consume alcohol?
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No alcohol consumption
Occasional
Moderate
Heavy
If you consume alcohol, how much and how often? This is important because alcohol can affect the way that your body responds to treatment, as well as how well your body is able to heal.
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Do you use any substances that may alter the mind and/or body in any way? (Includes CBD, Delta Products, Kava, Kratom, 7-OH, Marijuana)
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Yes
No
Sometimes
How much caffeine do you have on a daily basis? (coffee, soda, tea, energy drinks, etc.)
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What is your stress level currently (0-10 scale), and how do you manage stress? This is important because increased stress leads to cortisol and inflammatory changes in the body which can affect your overall health and wellness, as well as healing post treatment.
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Approximately how many hours do you sleep per night? Do you wake feeling well rested?
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Do you have any physical limitations that make exercise difficult for you?
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How many times per week do you work out intentionally?
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None currently
1 day per week
2-3 days per week
4-5 days per week
5+ days per week
What does your physical activity look like? (cardio, weights, yoga, biking, etc.)
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What type of diet do you currently follow?
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Regular - No Restrictions
Carnivore
Paleo
Pescatarian
Vegetarian
Vegan
Calorie Restricted
Carbohydrate Restricted
Keto Diet
Intermittent Fasting
How much water do you drink daily?
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Acknowledgments (there will be a consent form required at time of treatment)
I agree to see my primary care physician, gynecologist, or other practitioner for regular monitoring and for preventative measures that may include but are not limited to complete physicals, rectal examinations and/or colonoscopy, EKG, mammograms, pelvic/breast exams, pap smears, prostate exams, PSA levels, etc. at least on a yearly basis. I agree to immediately report to my physician any adverse reaction or problem that might be related to my treatment with Coastal Wellness NC.
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Yes
I agree to comply with requests by the nurse practitioner for ongoing testing to assure proper monitoring of my treatments that may include laboratory evaluation of basic labs and/or other diagnostic testing by my primary care physician, or other specialist.
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Yes
I certify that I have read or have had this form read to me, and that I understand its contents. I agree not to undergo any treatments unless I fully understand the treatment and have discussed possible risks, benefits, and side effects with the provider.
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Yes
I acknowledge with my signature on this form that all of the above health information on the questionnaire is complete and accurate.
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Yes
Signature
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Submit Consultation Form
Submit Consultation Form
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