CLIENT INTAKE FORM

PERSONAL INFORMATION

Name(Required)

First Last

Date of Birth(Required)

Home Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Home Telephone

Work Phone

Cell Phone(Required)

Email(Required)

This gives us permission to contact you regarding:

Products

Treatments

Promotions

MEDICAL HISTORY

Height

Weight

Lowest Weight

When?

Highest (Non-Pregnancy Weight)

Goal Weight

Please list all allergies (including medications, food, poultry, latex, cosmetics, lidocaine):(Required)

Please list all medications, including herbal over the counter, you take on a regular basic, or have taken in the last six months:(Required)

List all operations (including plastic/laser procedures) Hospitalizations, and any serious illnesses:(Required)

What are your concerns? Please list all.(Required)

For our female clients: Are you pregnant or trying to become pregnant? Are you using contraception? Are you breastfeeding? Have you ever smoked?(Required)

Signature

Sign Date

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