• Comprehensive Aesthetic Medical Evaluation and Good Faith Examination

    Please thoughtfully complete all fields so that we can best invest in you.
  • Format: (000) 000-0000.

  • Part I: Medical History

    This form will be updated annually.
  • Do you have a history of migraines or chronic headaches?
  • Do you have a history of seizures or seizure disorders?
  • Do you have a history of neurological or neuromuscular disorders?
  • Do you have a history of Bell's Palsy or facial nerve disorder?
  • Do you have a history of recurrent cold sores or HSV?
  • Do you have a history of Dysphagia or breathing disorders?
  • Do you have a history of cardio vascular disease?
  • Do you have a history of Hypertension?
  • Do you have a history of bleeding or clotting disorders?
  • Do you have a history of liver or kidney disease?
  • Do you have a history of Diabetes?
  • Do you have a history of autoimmune or connective tissue disease?
  • Do you have an immunocompromising condition?
  • Do you have a history of Cancer or Cancer treatment?
  • Do you have any or have a history of skin diseases, active rashes, infections or open wounds?
  • Do you have or do you have a history of keloids, hypertrophic scarring, or poor wound healing?
  • Do you have any current fever, illness or infection?
  • Have you had a recent hospitalization or surgery?
  • Do you have any other significant medical conditions?

  • Part II: Medication History, Allergies and Reproductive Status

  • Please check any medications you are currently taking.
  • Please check any of the following allergies that apply to you.
  • Do any of the following describe your current reproductive status?

  • Part III: Recent Events & Previous Treatments

  • Please check any of the following recent health events that apply to you.

  • Previous Aesthetic Treatments

    Please provide all information requested regarding previous treatments.
  • Approximate Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Client Attestation

  • I certify that the information provided is accurate and complete to the best of my knowledge. I understand that omitted or inaccurate information may affect my eligibility for treatment and increase the risk of complications. I agree to notify Solstice Regenerative Institute of any changes before receiving treatment. I agree that my electronic signature is the legal equivalent to my manual/handwritten signature on this document.

    Require electronic signature and automatic date/time.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Part II: To Be Filled Out By Provider

  • Encounter Informatoin

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • In person visit or telehealth visit?
  • New or Established Client?
  • Provider
  • History Review

  • Focused Physical Examination

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  • Final Decision & Assessment to Treat

  • Approved or Denied
  • If Denied
  • Authorized Treatment Categories

  • Treatment for Medical Weight Loss

  • Medication Choice
  • Follow Up Appointment
     - -
    2 digit month, 2 digit day, 4 digit year

  • Provider Certification

    I completed an medical evaluation, reviewed the client’s relevant history, performed the examination indicated by the proposed treatment, assessed contraindications and risk factors, and determined the client’s current medical eligibility for the treatment categories documented above. This evaluation does not replace procedure-specific informed consent or the clinical reassessment required on the treatment date.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: