Client Intake

Basis Medical & Aesthetics

2702 N. Federal Highway

Delray Beach, FL 33483

www.basisaesthetics.com

(561) 7742296
New client Intake Form:
Full Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Best Way to Reach You*

PhoneEmail
How did you hear about us?*
Please Specify*
Areas of Concern : (Please choose all that apply)*

Lines/WrinklesSkin LaxitySkin TextureScarringBrown Spots/HyperpigmentationBelly FatFlanksUpper ArmsBra FatFlanksUpper ArmsBra FatInner ThighsOuter ThighsBanana Roll (Under Buttocks)Above the KneeBelow The JawlineUnder ChinForehead CreasesWrinklesLoss of Volume in MidfaceFrown LinesCrow's FeetThin LipsHormone Replacement TherapyOther
Medical History :*

Active Implants : Pacemaker/DefibrillatorHerpes or Cold SoresMetallic ImplantsHemorrhagic or Bleeding DisordersPregnant or NursingDiabetesMigrainesAnxiety/DepressionNeuropathyRecent Dental WorkNeuromuscular Disorder / Bell's PalsyHerniaEpilepsy/SeizuresAutoimmune DiseaseHigh Blood PressureHeart DiseaseLiver DiseaseImmune CompromisedHIVIUD/Mesh ImplantsIodine/Latex AllergyNone Apply
List any chronic illnesses: (please put N/A if not applicable)*
List any drug allergies: (please put N/A if not applicable)*
Any other allergies we should be aware of: (please put N/A if not applicable)*
Are you 18 years or older?*

YesNo
Signature : (If you are under 18 please have your parent or guardian sign)*

Powered by Jotform SignClear
Today's Date :

MonthDayYear
Date
Please upload a copy of your license :

Cancelof
Should be Empty:

New client Intake Form: