Actualize Welcome Form

1
Full Name* This field is required.
First Name
Middle Name
Last Name
2
Date of Birth
Date
Month
Day
Year
3
Cell Phone* This field is required.
Please enter a valid phone number.
4
Email Address
example@example.com
5
Emergency Contact Name & Phone
6
How did you hear about us?
Please Select
Please Select
Google
Social Media
Friend/Referral
TV
Other
7
Are you pregnant, nursing, or trying to conceive?* This field is required.
No
Yes
Unsure
8
Are you currently under a doctor's care for any condition?* This field is required.
No
Yes
9
If "yes" please briefly describe
10
Are you currently taking any of the following medications or supplements?* This field is required.
Blood pressure medication
Blood thinners (aspirin, warfarin, etc.)
Antibiotics
Acne medication (Accutane, doxycycline, etc.)
Hormone therapy / birth control
Diabetes medication
Antidepressants / antipsychotics
Steroids or immunosuppressants
Vitamins / supplements only
None of the above
11
Known allergies — medications, foods, topicals, metals, latex, seafood/fish, nuts, papaya, pineapple* This field is required.
No known allergies
Yes
12
Please list your allergies.
13
Have you used any of these in the past 6 months?* This field is required.
Accutane / Isotretinoin
Prescription retinoids (Retin-A / Tretinoin)
Topical steroids or prescription acne medication
Photosensitizing medications (tetracycline, doxycycline, St. John's Wort, some diuretics)
Blood thinners
None of the above
14
Have you had any of these recently?* This field is required.
Botox / fillers (within 4 weeks)
Chemical peel, laser, or microneedling (within 4 weeks)
Surgery in the treatment area (within 6 months)
None of the above
15
Electrical & Light Treatments* This field is required.
Pacemaker or any implanted electrical/electronic device
Epilepsy or seizure disorder
Active cancer or currently in cancer treatment
Thrombosis, phlebitis, or vascular disorder
Metal plates, pins, or implants in the treatment area
Heart disease or irregular heartbeat
Photosensitive skin condition (solar urticaria, porphyria)
Thyroid condition
None of the above
16
Skin Surface & Temperature Treatments* This field is required.
Cystic or severe acne in the treatment area
Active cold sore, wart, or skin infection in the treatment area
Active eczema, psoriasis, or rosacea flare
History of keloid or hypertrophic scarring
Sunburn in the treatment area within 1 week
Allergy to seafood/fish, nuts, papaya, or pineapple
Raynaud's disease or cold-induced vasospasm
Impaired sensation or numbness in the treatment area
None of the above
17
Main concern today
Acne / breakouts
Fine lines / wrinkles
Hyperpigmentation / uneven tone
Loss of firmness
Redness / sensitivity
Dryness / dehydration
Pore size
Scarring
Muscle or joint pain
Other
18
By submitting this form, I confirm: I have answered all questions honestly. These are non-invasive aesthetic/wellness services, not medical treatments. Results vary and are not guaranteed. I consent to today's treatment and may withdraw at any time. I will notify my provider of any health changes before future visits.
19
I have read and agree to the consent statement above* This field is required.
I agree
20
Photo consent
Yes, clinical records only
Yes, records and marketing/social media
No
21
I acknowledge receipt of these practices notice of privacy practices (HIPAA)* This field is required.
I acknowledge
22
Signature
23
Date
Date
Month
Day
Year
24
Image Field
Should be Empty: