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Patient Intake Form

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INTAKE FORM

Date

*Name

*Date of Birth

*Age

Address

Gender

M

F

WT

HT

City, State, Zip

Phone

Email Address

Questionnaire

1. How much water do you drink in a day?

2. Do you drink alcohol?

Yes

No

-If yes, please indicate how many servings a day

3. Do you drink coffee?

Yes

No

-If yes, please indicate how many servings a day

4. Do you smoke?

Yes

No

-If yes, how much in a day?

5. Do you currently exercise?

Yes

No

-If yes, how many hours of exercise per week?

6. Are you currently following a lifestyle eating plan such as – Whole30, Keto, Vegan,Vegetarian, Paleo, etc.?

Yes

No

-If so, which one do you follow?

7. Are you currently experiencing weight fluctuations?

Yes

No

8. Are you currently trying to conceive?

Yes

No

9. Are you currently breast-feeding?

Yes

No

10. Do you spend time in the sun?

Yes

No

11. Do you wear sunscreen?

Yes

No

12. Do you have oily, dry, or combination skin?

Yes

No

13. Do you currently have a skincare regimen?

Yes

No

-If yes, what are you using?

14. Do you suffer from acne breakouts or ingrown hairs?

Yes

No

- If so, where?

15. How would you rate your pain tolerance from 1- 10?

16. Do you agree to have your photos taken at each visit?

Yes

No

17. Do you agree to have your weight taken at each visit?

Yes

No

18. How did you hear about us?

19. Would you like to be notified of your appointments and promotions via email or text message? -If yes, please include your email and cell phone number

Phone

*Email

20. Do you have a social media account you would like to share with us?

Yes

No

21. Do you consent to your photos being used for marketing?

Yes

No

Please check the boxes of minimal to non-invasive procedures you
are interested in now, or in the future:

Treatment

Now

Future

Hair removal

Now

Future

Skin tightening face (eyes, lower face, forehead, nasolabial folds)

Now

Future

Skin tightening neck and/or submental

Now

Future

Skin tightening body (abdomen, knees, arms, inner thighs, hands, breasts)

Now

Future

Wrinkle reduction

Now

Future

Skin resurfacing

Now

Future

Skin rejuvenation

Now

Future

Pore reduction

Now

Future

Lip plumping

Now

Future

Acne

Now

Future

Acne scar correction

Now

Future

Hyperpigmentation on face

Now

Future

Hyperpigmentation on body

Now

Future

Vascular lesions on face, including Rosacea

Now

Future

Vascular lesions on body

Now

Future

Facial contouring

Now

Future

Body contouring

Now

Future

Cellulite reduction

Now

Future

Intra-vaginal tightening (incontinence, sexual pleasure)

Now

Future

Labia tightening

Now

Future

Preventative treatments for aging

Now

Future

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About our Clinicians
Form
The science behind the beauty
Services
Blog