Medical Intake Form

Medical Intake Form
First name*
Last name*
Birthdate*

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Address

Address

City/St/Zip

City/St/ZipState / Province

Postal / Zip Code
Height
Weight
Allergies to medications
Cell Phone
Home Phone
E Mail*
example@example.com
Occupation
How did you hear about us?*
Please check all Medical Conditions you have:

Bleeding tendencyDiabetesBlood TransfusionsGlaucomaDry eyesLung diseaseAsthmaHeart diseaseHigh Blood PressureHepatitis B or CHIVLupusDepressionDrug or alcohol addictionOther
List all current medications and those taken in the past 6 months including: Birth Control, Aspirin or ibuprofen, Weight loss medication, Coumadin, or any blood thinning medication, prescription eye drops, steroids, or antibiotics
List all surgeries you have had (including plastic surgery):
Date

MonthDayYear
Date
Surgery
Date

MonthDayYear
Date
Surgery
Date

MonthDayYear
Date
Surgery
Have you ever seen a dermatologist for your skin?

YesNo
Reason?
Are you pregnant or lactating?

YesNo
How many months?
Have you ever taken Accutane?

YesNo
When?
Do you have a history of cold sores?

YesNo
Last outbreak?
Do you have a history of developing Keloids?

YesNo
Describe
Do you have regular periods?

YesNo
Do you smoke cigarettes or use tobacco products?

YesNo
How often?
Do you use recreational drugs?

YesNo
How often?
Do you drink alcohol?

YesNo
How often?
Do you have:

EczemaPsoriasisMelanoma / Skin cancerAcneRosaceaVitiligoOther
Have you ever been diagnosed with cancer?

YesNo
What kind and when?
What topical medications do you use? (Retin A, Salicylic Acid, Glycolic Acid, Benzoyl Peroxide, Antibiotics)
What vitamins or supplements are you currently taking?
List all current skin care products
I am aware of the 48 hour cancellation policy. There will be a $50 cahrge per hour or portion thereof, for any treatment not cancelled at least 48 hours in advance.

By joining Calabasas Med Spa's Mobile Club, I agree to receive ongoing messages at the number provided. Msg & data rates may apply. Calabasas Med Spa will occasionally text appointment reminders, specials and flash sales. Up to 4 msgs/mo. Reply STOP to cancel, HELP for assistance. Mobile T&C / Privacy Policy @ https://latxt.me/W4C5E
Signature:*

Clear
Date:*

MonthDayYear
Should be Empty: