CLIENT INFORMATION FORM

CLIENT'S RECORD

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Name*

First NameLast Name
Age*
Number Only
Birthday*

MonthDayYear
Date
Gender*
Phone Number*
Occupation*
Email*
example@example.com
ADDRESS*

STREET,BLDG,BRGY

CITYCOUNTRY
How did you know about ETHOS SKIN AESTHETICS?*
Patient Status*

New PatientOld Patient
Appointment*
In which Non-surgical procedure you are interested in?*

FacialFNT/ MicroneedlingDiode Hair RemovalPico LaserBody ContouringMesotherapyAcne scar TreatmentsThreadsBotoxFillersSkin Booster/ BiostimulatorHikoHair and Scalp TreatmentsAround the Eye TreatmentMelasma TreatmentMD Peels/ ExfoliationIV Drip/PushFractional CO2 LaserWarts RemovalHyaluronidaseDerma ServicesConsultation Only
FACIAL

The Good FacialThe Better FacialKind FacialAcne Busting MD FacialHydrafacialOrganic Collagen FacialExosome FacialNatal Facial
FNT/ Microneedling Treatments

FNT ScarFNT BlemishFNT RefineFNT BrightFNT ReviveDermafirm Exosomes
Derma Services

Pimple InjectKeloid InjectWarts RemovalSkin Tag RemovalMilia RemovalSyringoma RemovalMole removalSclerotherapy
IV Drip/ Push

Gluta + Vitamin CGluta + Vitamin C + CollagenImmunity BoostClarity BoostDetox Vitality DripIlluminating Drip (AKA Hangover drip)Ultimate Goddess Drip
MD Peel Treatments

MD Peel MandelicMD Peel GlycolicMD Peel SalicylicCosmelan
Melasma Treatments

FNT BrightMesolasmaMD Melasma Protocol Pico LaserCosmelan
Around the Eye Treatments

Smaxel Lids tighteningPlasma Lid ShapingBionutri- EyesRejuran IEye Booster FillUltra EyesInch Thread FirmingFox Eye LiftFox eye Premium
Hair And scalp Treatments

Hair PRPPremium Hair ExosomesAlopecia Shot
Skin Booster/ Biostimulator

NCTF BionutriglowRejuran LiteHydrodeluxe Skin BoosterLuhiloLuhilo SnowRevok 50Ultracol Liquid ThreadliftPlinest PN Lift
Acne Scar Treatments

FNT BlemishTCA CrossSmaxel/ CO2 Fractional LaserScar Laser DuoPRP Vampire FacialSubsicion w/ PRPSmaxel w/ PRPRejuran ScarPremium Exosome Treatment
Are you currently under a physician's care?*

NoYes
If Yes, since when? and Why?
Are you routinely taking any medication, herbal supplements, vitamins, or substances?*

NoYes
If Yes, please list.
Please choose if you have allergies on the following

FoodMedicineMetalLatexAnestheticsNone
If you have allergies, please specify
Have you taken aspirin or any other anti-inflammatory drugs in the past 14 days?*

NoYes
Are you pregnant or suspect you may be?*

NoYes
Have you ever been treated for or been told you might have heart disease?*

NoYes
Have you ever had any of this?Please choose if you have allergies on the following

SurgeryRadiation TreatmentChemo Treatment for TumorRheumatic FeverHeart MurmursDiabetesHigh or Low BloodEpilepsy or SeizureAsthmaAny Systemic DisorderPacemaker or Artificial heart valve implantAnemiaLukemiaBled excessively after being cut or injuredPsychiatric TreatmentGoiter or Thyroid disorderNone
Do you have any disease, condition, or problem not listed? Please list down.
Have you ever had previous treatments such as*

Botulinum ToxinFillersThreadsSculptraPDRNBiostimulatorNoneOther
Please specify area, previous reactions or concerns related.
LIABILITY RELEASE ACKNOWLEDGEMENT AND WAIVER:
The undersigned understands, acknowledges and agrees that (i) l am aware that the facilities and services offered by Ethos Medispa Operations referred to as EMO involve risks; (ii) the information I have provided above is accurate and complete regarding my current health status; (iii) I am seeking aesthetic medicine treatments of my own free will; and (iv) assume all risks associated therewith. In consideration of my being permitted to use these facilities and services, on behalf of myself, my heirs and my assigns. I hereby release and discharge the entity that operates Ethos Medispa Operations (the Owner), and all of their affiliates, subsidiaries, employees, directors, officers, insurers, agents, landlords, representatives, successors and assigns from any and all claims, causes of actions, suits, damages, judgements, executions or demands, including court costs and reasonable attorney fees arising out of or relating to my aesthetic treatment, including but not limited to those resulting from bodily injury, theft, loSs of, or damage to property of mine.
Client Signature*

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PRIVACY NOTICE

At Ethos Skin Aesthetics, we respect your privacy and are committed to protecting your personal information. We use the details you provide only to manage your account and to deliver the treatments, products, and services you request from us. We may also contact you occasionally to update you about your progress, share clinic updates, and inform you about services or offers that may interest you. Your information will be handled with care and kept confidential at all times.
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CLIENT'S RECORD