Medical Aesthetic Clinic Client Intake Form
Personal Information
Full Name
Date of Birth
Email Address
Phone Number
Address
Medical History
Allergies
Current Medications
Medical Conditions (e.g. heart disease, diabetes, etc.)
Past Surgeries or Hospitalizations
Are you currently pregnant or breastfeeding?
Yes
No
Lifestyle
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Treatment Interests & Goals
What are your treatment goals or concerns?
Which treatments are you interested in?
Consent & Signature
Signature
Date