• Medical History Form

    Standard online medical history form for Bella Glow Concierge Aesthetic LLC.

  • Patient Information

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

  • Medical Screening Questions

  • Are you pregnant, breastfeeding or trying to get pregnant?*
  • Are you over the age of 18?*
  • Have you recently used Accutane in the past 6 months?
  • Are you currently taking antibiotics, or have you been on antibiotics in the last 7 days?
  • Do you have any current or active infections?
  • Are you allergic to Albumin?
  • Do you suffer from any nerve injuries or neurological disorders?
  • Do you have an Autoimmune Disorder?
  • Do you suffer from heart disease, congestive heart failure, and/or have any arrhythmias?
  • Do you have a history of a clotting disorder or are you taking any blood thinners?
  • Do you have a history of Herpes Type 1 or Type 2 (HSV)?
  • Do you have a history of kidney disease?

  • GLP1 Medical Weight Loss Screening

  • Are you over the age of 18?*
  • Are you pregnant, breastfeeding or trying to get pregnant?*
  • Do you have Type 1 or Type 2 Diabetes?*
  • Personal or family history of kidney disease, pancreatitis, medullary thyroid carcinoma (MTC), multiple endocrine neoplasia syndrome type 2 (MEN 2)
  • Do you have a history of Gastroparesis?*
  • Do you have a history of gallbladder disease?*

  • Important Information


    -All new patients are required to complete a $35 Good Faith Exam (GFE) with our medical provider before any treatment.
    -GLP-1 patients must complete a follow-up GFE before their 3rd month of treatment and every other month thereafter.
    -Preferred payment methods: Zelle, Cash, and Venmo. Credit card payments made through Square are subject to a 3.3%–3.4% processing fee.


    Thank you for choosing Bella Glow Aesthetics & Wellness

     

     

     

  • Signature Consent

  • Patient Signature Date*
     - -
  • Should be Empty: