Aeris Medical Patient Intake Form

THE FOLLOWING INFORMATION IS ENCRYPTED AND WILL BE USED TO HELP PLAN SAFE AND EFFECTIVE SERVICES EACH TIME YOU VISIT AERIS MEDICAL AESTHETICS. YOUR PERSONAL INFORMATION IS FOR AERIS MEDICAL AESTHETICS USE ONLY AND WILL NOT BE SHARED WITH ANY PERSON OR ENTITY OUTSIDE AERIS MEDICAL AESTHETICS . IT IS IMPORTANT YOU ANSWER ALL QUESTIONS TO THE BEST OF YOUR KNOWLEDGE AND HONESTY.

Patient Name*

First NameMiddle InitialLast Name

Patient Birth Date*

MonthDayYear

Patient Gender*

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Best Phone Number*

Area CodePhone Number

Patient E-Mail*

example@example.com

Patient Employer

Patient Occupation

How Do You Foresee Paying for Your Services?

Patient Photo*

I give AERIS MEDICAL AESTHETICS permission to contact me regarding products, treatments, and promotions at all the above methods.

Sign using your finger

Emergency Contact Name*

First NameLast Name

Emergency Contact Number*

Area CodePhone Number

I give AERIS MEDICAL AESTHETICS permission to use my before/after photo and or training videos for marketing purposes. This may include Snapchat, Instagram, Facebook, Twitter and webpage.

Sign using your finger

Please list all allergies (including medications, food, poultry, latex, cosmetics, lidocaine, etc.)*

Please list all current medications, including herbal (esp. St John’s Wort) or over the counter, you take on a regular basis, or have taken in the last six months: *

What are your concerns? (please check any of the following):

Please check any of the following that apply to you

	Yes	No
Diabetes
High Blood Pressure
Frequent Headaches
Seizure or epilepsy disorder
Active skin disease/lesions
Active infection, Staph infection
Cancer, skin cancer, melanoma
Serious cardiac disease, blood clots, stroke
Bleeding problems with cuts, surgery
Jaundice or Hepatitis
Dizziness, palpitations, fainting spells
Cold sores, mouth blisters, fever blisters
Weight change of 10 lbs. in last 6 mo.
Psychiatric Disorders
Hormone imbalance
Herpes
HIV/Aids or Hepatitis
Keloids/scars
Vitiligo, scleroderma, lupus, hives
Tattoos or permanent makeup
Depression
Anxiety
Pain/Chronic Pain

If you checked yes to any of these answers above please explain

What is your nationality/ancestry?*

Have you ever used Accutane?

YesNo

If yes, when did you last use it? What topical medications or creams are you currently using? Retin-A, others (please list):

Check any of the following medications you have taken in the last 6 months (as they may increase hair growth):*

For our Female clients:*

	Yes	No
Are you pregnant or trying to become pregnant?
Are you using contraception?
Are you breastfeeding?
Are you menopausal or post-menopausal?
Are you on any type of hormone replacement therapy?
Are you smoking tobacco?
Are you smoking electronic cigarettes (vapor cigarettes)?
Do you consume alcohol?

If yes to any of the above please describe:

How Much? How Long? When Did you Quit?

I certify that the preceding history statements are true and correct. I am aware that it is my responsibility to inform my service provider of my current medical or health conditions. It is my responsibility to inform my service provider of any changes to preceding information.*

Sign using your finger

Cancellation Policy

Patients must provide notice of cancellation at least 24 hours prior to their appointment.

NOTE: This policy applies to patients who cancel or reschedule an appointment outside of our policy, as well as patients who do not show for their scheduled appointments. There will be a $50 no show fee that must be payed prior to rescheduling.

Whom may we thank for referring you?*

If through internet search, please tell us what source or words you searched

If you have any questions or concerns, please call our office at 505-433-4043. Or contact your provider directly.

Amanda Armijo- Amanda@aerismedical.info

Tyler Owen - Tyler@halomedspaabq.com

Lawrence Armijo- Lawrence@aerismedical.info

Aeris Medical Aesthetics — Results, No Guarantee, Policies, Assumption of Risk & ReleaseI understand that although good results are expected, no guarantee or warranty, express or implied, has been made regarding the results of any treatment, service, or product provided by Aeris Medical Aesthetics (“Aeris”). I understand I may not be completely satisfied with the outcome and that I may require additional and/or ongoing treatments to achieve or maintain desired results.I acknowledge that aesthetic services are not intended to diagnose, treat, cure, or prevent any disease or medical condition, and do not provide immunity against the occurrence or recurrence of any condition. I understand that results are temporary and vary by individual, and the duration and degree of results may be affected by factors including, but not limited to: skin condition, degree of skin irregularity, severity of volume loss, age, medical history, metabolism, lifestyle, adherence to pre/post-care instructions, sun exposure, prior procedures, trauma to the treated area, and personal goals.I understand that all sales are final. No refunds are available for products, services, packages, prepaid services, memberships, or promotional pricing, except where required by applicable law or expressly stated in writing by Aeris.I confirm that I have read and understand the information provided to me, that I have had the opportunity to ask questions, and that all my questions have been answered to my satisfaction. I agree to follow Aeris’ pre-care and post-care instructions and understand that failure to follow these instructions may increase the risk of complications and may negatively affect results.Except where prohibited by law, I knowingly and voluntarily assume all risks associated with products and services provided by Aeris, including the risk of injury, adverse reaction, complications, or other outcomes. To the fullest extent permitted by law, I agree to release, waive, discharge, and hold harmless Aeris Medical Aesthetics, including its owners, medical director (if applicable), providers, employees, contractors, representatives, agents, successors, and assigns, from any and all claims, demands, damages, liabilities, costs, or causes of action arising out of or related to my products or services, including claims of negligence, except where prohibited by law.This agreement, together with Aeris’ policies and procedures (including post-care plan rules and regulations), constitutes the entire agreement between the parties related to these services and may be modified only by a written agreement signed by both parties.I understand that Aeris Medical Aesthetics strives to maintain a safe, tranquil, and professional environment. Inappropriate, unsafe, or disruptive behavior may result in discontinuation of services, and I remain responsible for charges incurred in accordance with Aeris policies and applicable law.If I purchase a series/package of treatments, I understand the series must be completed within six (6) months of purchase unless otherwise stated in writing by Aeris. I understand that prepaid services are non-transferable to another client. If I choose to change my recommended program, I understand any promotional pricing, discounts, or package benefits may be forfeited. I acknowledge again that there are no refunds, except where required by law.By signing below electronically, I acknowledge and agree to the terms above.*

I understand and agree.

Patient Signature & Date*

Sign and date using your finger

Patient Information

Medical History

SKIN HISTORY