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Client Registration Form
Monroe MedSpa
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1
Name
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First Name
Last Name
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2
Date of Birth
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mm-dd-yyyy
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3
Emergency Contact Info
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Emergency Contact Name and Relationship
Please enter their cell phone number.
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4
How did you hear about us?
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5
If you were referred by a friend, please write their name below.
You consent by signing this form at the end to allow Monroe MedSpa to disclose your identification to the below listed individual.
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6
Are you taking any medications currently?
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Yes
No
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7
If yes, please list it here
Please list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed. If more than one, separate them with a comma.
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8
Have you had Botox-Xeomin-Dysport, Fillers, Microneedling, or Laser treatments before?
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YES
NO
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If yes, please list what treatments you have received and when you received them.
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10
Are you allergic to any of the ingredients in Botox-Dysport (eg. Albumin/egg allergy), or to Local Anesthetics like Lidocaine or Xylocaine?
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YES
NO
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11
Do you suffer from any disease that affects your nerves and causes a generalized weakness of muscle strength (i.e. myasthenia gravis, Eaton-Lambert syndrome)?
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YES
NO
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12
Do you have a history of large, raised or thick scars or keloid scars?
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YES
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13
Do you have a history of severe, life-threatening allergic/anaphylactic reactions or other multiple severe allergies?
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YES
NO
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14
Have you had a previous serious reaction to moisturizing creams or other hyaluronic acid products?
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YES
NO
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15
Do you have a serious preexisting disease such as diabetes, congestive heart failure, uncontrolled coronary artery disease, Rheumatoid arthritis, lupus, Hepatitis-C, HIV-AIDS or any other or have you undergone transplant surgery?
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YES
NO
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16
Any other medical concerns that we should know about?
If the answer is Yes please describe below:
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17
Signature
I attest the above information to be true, knowing my physician relies on this information to provide safe and effective treatment.
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18
Thank you for completing this form! Please hit submit! :)
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