Patient Intake Form

Name(Required)

First/Given Last/Family

Birthdate(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Email(Required)

How would you like to be contacted?

May we leave a message?(Required)

Yes

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How did you hear about us?

Emergency Contact

Name

First Last

Relationship:

Phone

Family Doctor

Name

Cosmetic Consultation Questionaire

(all of this information will be held strictly confidential)

Today's Date

Occupation

Referred By

Current Medical Problems or Recent Surgeries

Pre-Existing Medical or Skin Conditions

Current Medications

Allergies

What Are Your Main Areas Of Concern?

Please check all that apply

What areas are you interested in treating?(Required)

What Previous Cosmetic Treatments or Procedures Have You Had?

What areas have you had treated and when was the last date of treatment?(Required)

Laser Hair Removal

Recent hair removal method used and date of treatment.(Required)

Laser Hair Removal

Please check those that apply:

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Emergency Contact

Cosmetic Consultation Questionaire

Products

Company