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Patient Intake Form

If you’ve been instructed by Facial Rejuvenation to complete this form, please complete and submit it prior to your appointment.
  • Please answer yes or no to the following. Do you have:

  • I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. I understand that if any changes occur in my medical history / health, I will report it to the office as soon as possible. I have read and understand the above medial questionnaire. I acknowledge that all answers have been recorded truthfully and I will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form.

  • The Area Below This Text Box is For Our Medical Director. You, our super awesome client, can ignore it!

  • According to this client's health history, he/she is approved for Neurotoxins, Dermal Filler, Kybella Ultrashape, CO2re Fractional Laser / Vaginal Rejuvenation, Skin Tightening, Scleratherapy, PDO Threading, Chemical Peels, Microneedling, Latisse and / or Profound unless noted.

  • MD Signature // Date:

  • Kristen Shimp CRNP