Name

Email

Phone

Date of Birth

Emergency Contact and Phone

Height

Weight

Primary Care Provider (optional)

I confirm that I am 18 years or older I confirm that I am 18 years or older YES NO

Medical History (Check all that apply) Medical History (Check all that apply) High Blood Pressure Diabetes (Type I/ Type II) Heart Disease Thyroid Disorder Autoimmune condition Blood clotting disorder Cancer (past or present) Seizure disorder Liver disease Kidney disease PCOS Anxiety or depression Keloid scarring Skin conditions (eczema, psoriasis, acne, etc.) Recent illness or infection None of the above

If yes, please explain:

Surgical and Procedure History Surgical and Procedure History Cosmetic surgery Liposuction Recent surgery (within last 6 months) Medical implants or devices

Details and Dates

Medications and Supplements Medications and Supplements Blood thinners Weight loss medications Hormone therapy Steroids Herbal Supplements Vitamins

List of all medications/supplements

Pregnancy and Breastfeeding Pregnancy and Breastfeeding I am pregnant I am breastfeeding I am not pregnant or breastfeeding

Allergies Allergies Medications Latex Lidocaine Food None

Please list allergies

Skin and Healing History Skin and Healing History Easy bruising Slow wound healing Hyperpigmentation Sensitive Skin History of scarring

Service Intrest (check all that apply) Service Intrest (check all that apply) Weight loss / metabolic therapy Body refinement therapy injections Post-operative lymphatic drainage RF skin tightening PRP treatments BB Glow / skin rejuvenation

Other

CLIENT ACKNOWLEDGMENT CLIENT ACKNOWLEDGMENT I certify that the information provided is true and complete to the best of my knowledge. I understand that withholding information may increase risk and affect treatment outcomes.

WEIGHT LOSS & INJECTION MEDICAL SCREENING (ADD-ON) WEIGHT LOSS & INJECTION MEDICAL SCREENING (ADD-ON) History of pancreatitis Gallbladder disease Thyroid cancer (personal or family history) Eating disorder history GI disorders (IBS, Crohn’s, GERD) Nausea or vomiting sensitivity

If yes, which one and dosage?

INJECTION CONSENT CONFIRMATION INJECTION CONSENT CONFIRMATION I understand injections may cause temporary redness, swelling, bruising, or discomfort I understand results vary and require compliance

Initials