Intake Form - Facial Rejuvenation

Name*

First Last

Birthdate*

Phone Number*

Address

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

Email Address

Would you like to subscribe to our newsletter?

Yes
No

Who is your Primary Care Physician?*

How did you find us?

Please List Any Allergies

Please List Any Medications

What areas are you most unhappy about when it comes to aging?

Please answer yes or no to the following. Do you have:

A disease that affects your muscles and nerves (ALS or Lou Gehrig's Disease), myasthnia graves or Lamber-Eaton Syndrome?*

Yes
No

Allergies to any botulinum toxin product?*

Yes
No

Had any side effect from any botulinum toxin product?*

Yes
No

A breathing problem such as asthma or emphysema?*

Yes
No

Swallowing Problems?*

Yes
No

Bleeding Problems?*

Yes
No

Had surgery or plan to have surggery on your face?*

Yes
No

Weakness of your forehead muscles, such as trouble raising your eyebrows?*

Yes
No

Drooping Eyelids that is not age related?*

Yes
No

Any other change in the way your face normally looks?*

Yes
No

Are you pregnant / breastfeeding or planning to become pregnant in the next three months?*

Yes
No

Do you have a cutaneous auto-immune disease (ex. Scleroderma, active systemic lupis) // Are you on any immunosuppressants?*

Yes
No

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.

Digital Signature

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.

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:

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