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Name you prefer to be called
Street Address Line 2
State / Province
Postal / Zip Code
Preferred contact method
Would you like to be added to our email newsletter?
Emergency Contact Name and phone number
What are your goals for your skin health?
Lines around nose/mouth
skin texture/pore size
Age Spots/Brown Spots
Uneven skin tone
Have you had any of the following procedures in the last 6 months?
What products, topical or internal, are you currently using for your skin?
What medications, prescriptions, and supplements are you currently taking?
Do you have any of the following skin conditions?
Do you have any of the following health conditions?
History of Migraines
High Blood Pressure
Currently using Blood Thinners
Is there anything else that you'd like to share that you think may be helpful for your treatments?
Do you have any other concerns for your general, overall health?
I certify that I have read the consent agreement and fully understand it. These items have been reviewed and discussed with the Acupuncturist and all my questions have been answered to my satisfaction. I also agree to hold harmless and release from any liability Lee Cosmetic Acupuncture or any of its officers, directors and / or employees for any condition or result, known or unknown that may arise as a result of any treatment that I receive.
I am undergoing treatment of my own free will. I agree that this procedure is being performed for cosmetic reasons. I am also aware of and accept the risk of unforeseen complications that may not have been discussed and which may result from this treatment.
I acknowledge my obligation to follow the instructions closely and visit the office as directed.
I consent to the treatment of Cosmetic Acupuncture and/or Microneedling to be carried out upon myself.
Results Gaurantee: While Cosmetic Acupuncture and Microneedling has been clinically shown to work; we want to remind you that everyone’s body, skin, and repair process works differently. The purpose of Cosmetic Acupuncture is to create a younger and more vibrant appearance. Please be advised that this treatment is not a surgical procedure and cannot be compared to a surgical facelift. Lee Cosmetic Acupuncture cannot be held liable or bear any responsibility for the actions or results of actions of its Members, nor can we provide guarantees as to the success, or results of treatments delivered by Lee Cosmetic Acupuncture.
Do not Agree
Do you acknowledge and understand the Mandatory Disclosure Statement?
How did you hear of us?
By signing this form I agree to abide by policies and pocedures of Lee Cosmetic Acupuncture and consent to treatment.
Thank you for taking the time to fill out this health intake form. We look forward to working with you!
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