Client Intake Form

Client Intake Form

Welcome to The Clinic at Beverly Hills Medspa
Client's Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
What Services are you interested in?

Skin TighteningMorpheus8Non Surgical FaceliftLook 10 years younger packageNon Surgical Tummy tuckFat loss PackageBody ContouringHollywood Carbon PeelCellulite RemovalWrinkle ReductionFace/body slimmingDouble Chin RemovalMedical Grade SkincareBotoxFillersLip PlumpingJaw DefinitionIV vitamin infusionPRPMesotherapyAcne Scar RemovalOther
Are you interested in any of the following surgical Procedures?

Tummy TuckBreast AugmentationBreast LiftBBL (Brazilin Butt Lift)Mommy MakeoverLiposuctionOther
How did you hear about us?

FacebookInstagramWebsiteAdsCosmetic LaneFriend/FamilyOther
Terms & Conditions
I UNDERSTAND THAT MY DATA WILL BE STRICTLY CONFIDENTIAL. THIS CLIENT DOES NOT SELL, SHARE OR RESELL INFORMATION. I CONFIRM THAT ALL MY INFORMATION IN THIS FORM IS TRUE AND ACCURATE. I CONFIRM THAT IF SOME IMPORTANT INFORMATION AND/OR COMPLICATIONS OCCUR, THE CLINIC WILL NOT BE HELD LIABLE. I RELEASE THE CLINIC AT BEVERLY HILLS MEDSPA AND HOLD HARMLESS AGAINST ANY CLAIMS, EXPENSES, DAMAGES, AND LIABILITIES.
Client Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Terms & Conditions