Dermal Filler Client Intake Form
Client Information
Name
First Name
Last Name
Day of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Allergies
Medical History
Medical Conditions
Eye Disease
Vision Problems
Parkinson’s Disease
History of Cold Sores
Keloid Formation
Lambert-Eaton Syndrome
Muscle Weakness
Hypersensitivity to medications
None
Other
Other medical problems not listed above should be included and/or explained:
Have you ever had a plastic surgery?
Yes
No
If the answer is yes, please explain it more detailed way.
Have you had Dermal Filler before?
Yes
No
If the answer is yes, please explain it more detailed way.
Date
-
Month
-
Day
Year
Date
Patient Signature
Submit
Should be Empty: