PATIENT PROFILE

In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All information is strictly confidential.
PERSONAL INFORMATION
Full Name *

First Name Last Name
Date *

Month Day Year
Date
Date of Birth *

Day Month Year
Age *
Occupation *
E-mail *
example@example.com
Home Address *

Street Address

Street Address Line 2

City State

Post Code
Home Phone Number *
Cell Phone Number *
Sex *

Male Female Other
What is your ethnic background? *
Who should we contact in an emergency? *

First Name Last Name
Contact's Phone Number *
Please enter a valid phone number.
How were you referred to us? *

ACKNOWLEDGEMENT
I do understand that there is a 24-hour cancellation notice. If I fail to notify Limitless Medspa within that time frame, will be charged $100 for Physician appointments and $50 for non-physician appointments.
I understand the above cancellation policy *

Agree Disagree
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
I agree with the above statement *

Yes No
Patient Signature *

Clear
Date *

Month Day Year
Date
Print Name *
Should be Empty:

	Yes	No
Cancer
Arthritis
Skin Disease/Skin Lesions
Seizure Disorder
Hyperthyroid / Hypothyroid
High Blood Pressure
Hepatitis
Keloid Scarring
Hormone Imbalance
Blood Clotting Abnormalities
Diabetes
HIV/Aids
Any active infection

	Yes	No
Are you pregnant or trying to become pregnant?
Are you breastfeeding?
Are you using contraception?

PERSONAL INFORMATION