FORMS | Wilmington AW

- INTAKE FORM -

First name

Last name

Date of Birth

Month

Day

Year

Age

Address

Phone

Email

Occupation

Emergency Contact

Emergency Contact Phone

How did you hear about us?

Friend or Family

Current Client

Internet/Social Media

Other

Name of person/place

What is your main reason/concern for your consultation?

More details if needed:

Have you been evaluated by another Aesthetic of Wellness practice?

No

Yes

Do you have any other health problems or medical conditions not listed above?

Do you have any allergies?

No

Yes

Please list ALL current medications (including OTC/herbal supplements)

Women Only:

Are you using contraception?

No

Yes

Pregnant or plan to become pregnant?

No

Yes

Breast-feeding or plan to breastfeed?

No

Yes

Regarding your treatment, are you someone who prefers:

A lot of detail

The bottom line

I certify that the preceding medical, personal, and skin history statements are true and correct. I understand that it is my responsibility to inform the aesthetician, nurse, or doctor of my current medical or health conditions and to update this history.

Signature

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Intake Form

- INTAKE FORM -