Basis Medical & Aesthetics
2702 N. Federal Highway
Delray Beach, FL 33483
www.basisaesthetics.com
(561) 7742296
New client Intake Form:
Full Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Best Way to Reach You
*
Phone
Email
How did you hear about us?
*
Please Select
Basis Medical
Facebook
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Employee
Family
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PureLife
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Please Specify
*
Areas of Concern : (Please choose all that apply)
*
Lines/Wrinkles
Skin Laxity
Skin Texture
Scarring
Brown Spots/Hyperpigmentation
Belly Fat
Flanks
Upper Arms
Bra Fat
Flanks
Upper Arms
Bra Fat
Inner Thighs
Outer Thighs
Banana Roll (Under Buttocks)
Above the Knee
Below The Jawline
Under Chin
Forehead Creases
Wrinkles
Loss of Volume in Midface
Frown Lines
Crow's Feet
Thin Lips
Hormone Replacement Therapy
Other
Medical History :
*
Active Implants : Pacemaker/Defibrillator
Herpes or Cold Sores
Metallic Implants
Hemorrhagic or Bleeding Disorders
Pregnant or Nursing
Diabetes
Migraines
Anxiety/Depression
Neuropathy
Recent Dental Work
Neuromuscular Disorder / Bell's Palsy
Hernia
Epilepsy/Seizures
Autoimmune Disease
High Blood Pressure
Heart Disease
Liver Disease
Immune Compromised
HIV
IUD/Mesh Implants
Iodine/Latex Allergy
None Apply
List any chronic illnesses: (please put N/A if not applicable)
*
List any drug allergies: (please put N/A if not applicable)
*
Any other allergies we should be aware of: (please put N/A if not applicable)
*
Are you 18 years or older?
*
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Signature : (If you are under 18 please have your parent or guardian sign)
*
Today's Date :
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Day
Year
Date
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