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Aesthetic Consult Intake Form

*Patient Name :

Last name

Mid name

First name

Birthday:

Age:

Gender: Male Female

*Address:

				City
Prov.		Postal		APT#

*Email Address:

AB Health Number:

Occupation:

*Home phone #:	()- -	Cell #:	()- -
Work phone #:	()- - -

How did you hear about Silverado Medical?

Would you like to be notified of special events, promotions, new products or services?

Yes No

How would you prefer to be contacted? Home Work Cell E-Mail

Emergency Contact Details-

His/Her Name:

Phone #:

()- -

ALLERGIES: Please list all allergies both prescription and non-prescription:

MEDICATION: Please list any medications you are currently taking and dosage, including all medications taken within the past month, vitamins and herbal remedies:

Are you currently being treated for any medical condition?

Yes No

If Yes, Explain:

Please list below any questions you would like to have specifically answered during your consultation.

Medical History

For women: Are you pregnant?	Yes No
For women: Breast Feeding?	Yes No
For women: Planning a pregnancy?	Yes No
History of skin cancer	Yes No
Problems healing	Yes No
History of Keloids	Yes No
Do you smoke	Yes No
Permanent makeup	Yes No
History of Cold Sores	Yes No

Please list any concerns you have with your skins appearance:

What products are you currently using on your skin:

Have you ever had the following cosmetic procedures:

Permanent Makeup

Accutane

Laser Treatments

Injected fillers

Chemical Peels

CoolSculpting

Botox

Microdermabrasion

Cosmetic Surgery

When was your last exposure to UV Rays:

Do you use Self-tanning creams:	Yes No
Do you give us permission to use your before and after photos for marketing purposes?	Yes No

24 HOUR POLICY
Appointments missed or cancelled without 24Hrs notification will be charged a missed appointment fee of $50.00 FINANCIAL POLICY
Unless other arrangements have been made in advance, full payment is due at the time of service.