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

Month Day Year
Date
Legal Name *

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

Month Day Year
Date
BC Care Card / Personal Health Number
Gender *
email:
example@example.com
Tel No: *
How may we contact you for appointment information? *

Email Telephone Text 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 consultation Follow up visit Second opinion Botox PRP for Hair restoration Acne Scar Treatments PRP Vampire Facial PRP for under-eye areas (dark circles) PRP for lines and wrinkles Dermal Filler Lip Filler Aging Hands O-Shot for women Priapus shot for men (increase size and function) PRP for joint problem (eg. tendonitis, arthritis)
Please indicate any other concerns you wish to discuss:
Medical History
Do you have ANY allergies to medications, food, latex, or other substances? *

Yes No
Please list any allergies or sensitivities here:
Have you taken ANY medication, herbal/ natural supplements or topical creams in the past 6 weeks? *

Yes No
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

Have you ever suffered from any of the following:

	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)

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	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