PATIENT INTAKE FORM
PATIENT INFORMATION
MR
MRS
LAST NAME
FIRST NAME
MAIDEN NAME
NICKNAME
DATE OF BIRTH
SUITE/ APT. #:
STATE
FEMALE
REFERRAL SOURCE:
FRIEND
CITY
ZIP
MS
MI
MALE
AGE
STREET ADDRESS:
MISS
FAMILY
COMMUNITY LIAISON
RADIO
TV
BILLBOARD
OTHER
PO BOX
EMPLOYER
EMAIL
OK TO EMAIL YOU?
YES
NO
PREFERRED CONTACT NUMBER
HOME
ALLERGIES TO MEDICATION?
YES
CELL
NO
ADDITIONAL NUMBER
IF YES, PLEASE LIST EACH:
EMERGENCY CONTACT NAME
MARITAL STATUS
DIVORCED
SINGLE
MARRIED
SEPARATED
WIDOW(ER)
PHONE NUMBER
RELATIONSHIP
WORK
VAL PAK
FACEBOOK
WHICH OF THE FOLLOWING BOTHER YOU ENOUGH TO PURSUE TREATMENT AT THIS TIME (OR NEAR FUTURE)?
WRINKLES
ACNE
ACNE SCARS
PORE SIZE
TATTOOS (WANT ONE OR
ONE REMOVED)
SKIN TONE
SKIN TEXTURE
BROWN SPOTS
BODY SHAPE
DARK UNDER EYE CIRCLES
“TURKEY NECK”
EYELASHES TOO THIN OR NOT ENOUGH
WEIGHT
FAT
OTHER
IF YOU HAVE TREATMENT OR SURGERY, HOW MUCH DOWNTIME AND/OR TIME OFF WORK CAN YOU DEVOTE TO YOUR RECOVERY?
DAYS
WEEKS
WHICH, IF ANY, OF THE FOLLOWING COSMETIC PROCEDURES HAVE YOU HAD?
BOTOX
FILLER (RESTYLANE/JUVEDERM ETC.)
FACIALS
MICRODERMABRASION
PHOTOFACIAL (IPL, BBL)
LASER HAIR REMOVAL
CELLULITE TREATMENTS
SKIN TIGHTENING
LASER RESURFACING
FACELIFT
LIPOSUCTION
OTHER
2000 FOUNDATION WAY, SUITE 3700 MARTINSBURG, WV 25401
P. 304.264.9080
F. 304.264.9082