Initial Consultation Form Face/ Body

First name

Last name

Birthday

Month

Day

Year

Email

Phone

Yes, subscribe me to your newsletter.

Treatments of interest

Face

Body

both

Other

Health & Medical History Please check all that apply:

If yes to any above, please provide details:

Are you wearing any eye contact lenses?

yes

no

IN CASE OF EMERGENCY, PLEASE CONTACT: Full name / relationship

Emergency phone number

Are you smoking? If yes, how many packs a day?

Are you wearing any implantable medical devices? If yes, what are these devices?

Are you currently taking any medications? If yes, please list them below:

Were you previously hospitalized? If yes, please indicate when and why:

Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:

Primary treatment goals:

What kind of pressure do you prefer?

Light

Medium

Firm

Authorization

I confirm that all information given in this form is true, complete, and accurate and will not hold Medical Aesthetics Bar responsible for anything that they were not aware of due to my lack of information.
I released Medical Aesthetics Bar for any responsibility in case of accident, illness, or injury.

Signature of Patient

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Parent/Guardian Name

Parent/Guardian Full Name

Signature of Parent/Guardian

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