Forms
Patient Intake Form
Name: ______________________________ Date of Birth: / / Age: ________
Address: ___________________________________
City:---------------State----------------------- Zip: _________________
Phone: _______________________________________ Email: ______________________________
Social media name Face book_________ IG ---------------
Who shall we thank for the referral----------------------- How did you hear about us? _____________
Employer: ________________________________ Phone: _______________________
Emergency Contact: Contact Number: ___________________________________________
Relationship: ___________________________________________________
Medical History
Ethnicity for skin treatment evaluation purpose ____________________________________________ Weight: ______________Height: ______________
List ALL past Medical History _____________________________________________________ _______________________________________________________________________________
_______________________________________________________________________________
List ALL Surgeries ___________________________________________________________
List ALL current medications including aspirin, ibuprofen, herbal remedies, vitamin supplements, blood thinners, fish oils, etc.
_________________________________________________________________ Facial Surgeries____________________________________________________
________________________________________________________________________________________
Primary Healthcare Provider: _________________________________________________________________________________________
*Do we have permission to contact your primary healthcare provider? Y / N
______ Allergies to medications, foods, latex, topical products or other substances.
If YES, Please List:--------------------------------------------------------------------
Please Mark any Current Conditions and/or Previously Experienced
______ Alpha Hydroxy Acid products ______Average daily Sun exposure time --------------------
---------- Computer exposure time----------------- Telephone exposure time____________
______ Antibiotics
______ Seizure history
______ Pregnancy/Nursing (Stage: ____________________)
______ Herpes or cold sores
______ Accutane in last 12 months
______ Retin A, Renova,Tretinoin salicylic acid, alpha/beta hydroxy/glycolic products
Please Answer the Following Questions:
Which concerns apply to you? (Check all that apply):
- Uneven Skin Tone
- Brown, Dark Spots (hyperpigmentation) MELASMA
- White Spots (hypopigmentation) ______ Excessive oiliness
- Skin Laxity _______ Droopy Skin
- Upper Lip Lines ________ Heavy laugh lines
- Wrinkles area _________________________________________________
- Scarring
- Unwanted Hair
- Rosacea REDDNESS TO CHEEKS NOSE area with heat,cold,stress,etc
- Spider Veins _____ Stretch Marks
- Cellulite _____ Unwanted Body Fat
- Black/White heads
- Acne _______Thinning Lashes Visible Exposed Blood Vessels
- Hard Bumps Under Skin
- Dry Patches
- Enlarged Pores
- Clogged Pores
- Keloids
- Other: _________________________________________________________________________________________________
What do you consider your skin type: Dry ,Combination , Oily, Normal, Sensitive
Please List any and all the products you currently use and list the brand names:
Facial Cleanser ____________________________________ Moisturizer________________________________________________
Toner______________________________________________
Anti-Aging Serum__________________________________________
Growth Factors____________________________________ Sunscreen_________________________________________________
Retinol_____________________________________________
Eye Cream_________________________________________________
Antioxidant________________________________________ Scrub_______________________Masks_________________HOME MADE PRODUCTS__________________
Are you using any topical creams, lotions, or oral antibiotics for acne, skin cancer, anti-aging or hyperpigmentation treatment prescribed by a Doctor?
PleaseList:_________________________________________________________________________________________________________
Have you ever had any of the following injectables or implants:
Botox Juvederm Radiesse Restylane Voluma Silicone Hylaform
Collagen Bellafill Sculptra Dysport Xeomin Other: ________________________________________________
*If so, when was it done? ______________What area? ________________________________________________
*Any problem with or after the procedure ? ______________What area? ________________________________________________
*Any side effect? ______________What area?____________________________ ________________________________________________
*Are you satisfied with the result? ______________If not explain why?____________________________________ ________________________________________________
Please Mark any Services You Would Like to be Educated On:
___ Physician Grade Skincare ___ Brightening Microderm +Peel +Laser
___ Microdermabrasion ___ Micro needling with PRP
___ PRP ___ Injectables (Botox, fillers, etc.)
___ Lip Augmentation ___ Facial Thread lifts-----
___ Laser Hair Reduction ___ Ultrasound or RF Skin Tightening----
__24 Karat Gold Event Glow ___ Laser Facials
___ Medical grade Skin Peels ___ Microblading (For eyebrows)
___ Non invasive fat reduction ____Sclerotherapy
___ Weight Loss ___ Hormone Therapy-------Fit DNA genetic testing
Thank you for taking the time to complete our Patient Intake form. With the following information, we will be better able to serve you. Our goal is to provide you with excellent uniquely tailored service and results. At future visits, please let us know if any of the previous information changes. All information and treatments are confidential.
Cancellation Policy
It would be greatly appreciated if appointments need to be cancelled, rescheduled, or the appointment type changed, that it be done at least 24 hours in advance. Should you fail to give us 24 hours’ notice to cancel or alter your appointment; a cancelation fee of $50 WILL be charged to the credit card on file OR a deposit for the full cost of future services will be required at the time of booking.
Initial that you have read and agree: _____________.
Payment Policy
We are committed to the success of your medical treatment and care. Please understand that payment for your services is part of your treatment and care. You will be responsible for the FULL payment the time of service. If a deposit is required, that will need to be paid prior to the scheduled appointment. If you need further information regarding our payment policy, please ask to speak with the practice or front office coordinator.
Initial that you have read and agree: _____________.
I understand that the results are not guaranteed. There are many variables that are beyond our control that affect the procedure outcomes, especially individual expectations. We maintain our equipment and continue staff education and training regarding technique. There are times when the human body does not respond as well as we would like. Lifestyle choices, diet, exercise, hydration, prior skin damage, sun exposure and many other factors affect the final results. All our patients are unique and have unique needs and expectations. Please discuss your treatment expectations with us prior to your treatment because there are NO refunds.
Initial that you have read and agree: _____________.
Patient/Representative Signature: _____________________________________________________________ Date: _________________________
Provider/Office Representative Signature: _____________________________________________________ Date: _________________________
Consent Form for Aesthetic Consultation and Recommended treatment
Consent Form for Aesthetic Consultation and Recommended treatment
An individual’s choice to undergo a procedure is based on the comparison of the risk to the potential benefit. Although most patients do not experience adverse complications, you should discuss your concerns and potential risks with your practitioner in order to make an informed decision. In some situations, it may not be possible to achieve optimal results with a single procedure and other procedures may be necessary. Although peak results are expected, there cannot be any guarantee or warranty expressed or implied on the results that may be obtained. I understand that no warranty or guarantee of specific result has been made to me. I realize that, as in all medical treatment, complications or delay in recovery may occur which could lead to the need for additional treatment, and could result in a delay to one’s normal daily activities and thus economic loss. I understand my practitioner may discover other conditions which require additional or different procedures than planned treatment. I authorize my practitioner and his or her associates, technical assistants and other health care providers to perform such other procedures which are advisable in their professional judgment.
I understand compliance and ensuring to follow recommended treatments, take home instruction is expected from me and I also understand my best results can occur over time and additional procedures may be required. I consent to the taking of photos before, during or after the procedure to document my progress. The nature of the elective procedure, its risks and potential complications have been fully explained to me along with available alternative treatments and their benefits and risks has been discussed. I understand I have the right to refuse treatment. I have been instructed to and agree to abide by all safety precautions and post treatment instructions and have been given to me. I understand no refunds will be given for received treatment and no guarantee(s) have been given regarding the results. I understand sometimes my recommended treatment or products may not achieve the desired improvement anticipated.
I release Bnatural Solution facility, medical staff, and other technicians from liability associated with this consultation, recommended products, treatments and procedure. This consent is voluntarily executed and shall be binding on my spouse, relative, legal representatives, heirs, administrators, successors and assignees. I also state that I read and write in English. _________________________________________________ Date:___________________________
Patient Signature__________________
Witness Signature__________________: ___________________________________________
Medical Provider Signature______________________________________________