Intake: New Patient Consultation Form

Intake: New Patient Consultation

Confidential Medical History and Aesthetic Interest Form
Thank you for visiting PRP Medical Aesthetics. This intake form will help us understand you better and achieve your aesthetic goals together. Thank you for taking the time to complete it.
Today's Date

MonthDay Year
Date
Legal Name*

First Name Last Name
Preferred name (optional):
Pronoun
Gender*
Date of birth*

MonthDay Year
Date
Now*

MonthDay Year
Date
Age (calculated, office use)
BC Care Card / Personal Health Number
email:
example@example.com
Tel No:*
How may we contact you for appointment information?*

EmailTelephoneText message
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How did you find out about us?
What are you interested in? (please check all that apply)

New consultationBioidentical Hormone Replacement (BioTE)Eyelid treatmentsFollow up visitSecond opinionBotoxPRP for Hair restorationPRP forPRP for Arthritis / Joint PainPRP for Sport InjuryAcne Scar TreatmentsPRP Vampire FacialPRP for under-eye areas (dark circles)PRP for lines and wrinklesDermal FillerLip FillerAging HandsO-Shot for womenPriapus shot for men (increase size and function)
Please indicate any other concerns you wish to discuss:
Medical History
Do you have ANY allergies to medications, food, latex, or other substances?*

YesNo
Please list any allergies or sensitivities here:
Have you taken ANY medication, herbal/ natural supplements or topical creams in the past 6 weeks?*

YesNo
Please list details of ANY medication, herbal or natural supplements or topical creams here:
Do you drink any alcohol? How much, how often? *
Do you smoke? How much, how often?*
If yes or maybe to any of the above, please provide details:

Have you ever had history of the following?*

	Yes	No	Unsure
Skin Disorder
Autoimmune Disease (Lupus, other)
Keloid scarring
Herpes or Cold Sores
Bleeding or clotting disorder
Active Infection
Hepatitis B or Hepatitis C
H.I.V.
Myasthenia Gravis, Amyotrophic Lateral Sclerosis any other Neuromuscular disorders
Anemia or iron deficiency
Thyroid disease, over- or underactive

Please list any other medical conditions
Previous Aesthetic Treatments

Please indicate if you have ever had any of the following procedures:*

	Yes	No
Botox (or Dysport, Xeomin, Nucieva, etc)
Dermal Fillers
Lip Fillers
PRP procedures
Cosmetic Surgery (including nose, facelift, etc)

Were you satisfied with your previous cosmetic procedures? Please provide details if appropriate
Please list any previous reaction or side effect to any cosmetic procedure you have had here:
Women's Health

Are you currently pregnant, trying to conceive or nursing?
Men's Health

Certification

I certify that I have answered all questions to truthfully to the best of my knowledge and will advise my treatment provider if there are any changes to my health history in the future.
Name Printed*
Patient Signature*

Clear
Please verify that you are human*
Should be Empty:

	Yes	No	Unsure
Bladder problems with coughing, sneezing, jumping, etc.
Frequent urination or bladder irritability / cystitis
Female sexual dysfunction
Dyspareunia (painful or difficult intercourse)
Lichen Sclerosis (itchy, painful pelvic skin condition)

	Yes	No	Maybe
Priapus Shot for increased size and improved function
Priapus Shot for Peyronie's disease (curved penis)

Intake: New Patient Consultation

Medical History

Previous Aesthetic Treatments

Women's Health

Men's Health

Certification