RN Aesthetics
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Neuromodulators (Botox/Dysport/Xeomin)
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Intake Form
Intake Form
Please fill in this form after making an appointment with RN Aesthetics.
Personal Information
First Name
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Last Name
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Date of Birth
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Gender
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Select...
Male
Female
Other
Address (Address, Province, Postal Code)
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Phone Number
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E-mail
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Medical Information
Name of Family Doctor
Family Doctor Phone Number
List any significant medical conditions you have. example: Diabetes, Autoimmune Disorders, etc
Have you ever had or currently being treated for, check all that apply.
Skin Conditions such as Eczema, Psoriasis
Acne
Rosacea
Cold Sores/Fever Blisters
Keloid Scarring
Chronic or Systemic Illness
Blood Disorders
Hepatitis or Liver Disease
HIV/AIDS
Cancer
Thyroid Disorders
Mental Health Conditions
Other (please specifiy)
Allergies:
Are you on any medications? If so, please specify:
Have you ever undergone any surgical procedures or had any significant injuries?
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Yes
No
Are you pregnant or trying to become pregnant?
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Yes
No
Are you currently breastfeeding?
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Yes
No
Treatment History
Have you ever received any of the following treatments? Check all that apply:
Botox/Dysport (Neuromodulator)
Dermal Fillers
Chemical Peels
Laser Hair Removal
Microdermabrasion
Laser Skin Resurfacing
Other (Please Specify):
Date of last treatment listed above:
Have you ever had any complications or adverse reactions from previous aesthetic treatments?
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Yes
No
Goals & Consent
What are you primary concerns or goals for seeking aesthetic treatments?
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Consent and Agreement: By signing below, I acknowledge that the information provided on this form is accurate and complete to the best of my knowledge. I understand that it is essential to provide honest and accurate information to ensure the safety and effectiveness of any aesthetic treatment I may receive. (Please write your full name here)
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Date Signed
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Submit Intake Form