♟Aesthetic Enhancements | New Patient Registration

Personalized Care ♟ Aesthetics

Let's get to know you...in private.
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Submission Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Patient Gender (at birth)*
Patient E-Mail*
example@example.com
Address: Please list the location you would like a service at. *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment
Phone Number*

Country CodeArea CodePhone Number
Preferred Method of Contact

EmailTextGood Old Fashioned Phone Call
I'm here to receive aesthetic and/or cosmetic enhancements:*

YesNo
Please check all that apply. I am interested in the following treatments:*

Botox/Wrinkle ReductionDermal FillersMicroneedling (+/- PRP)Thread LiftsChemical PeelsPigmentation Correction or treatment for spots, scarring or other skin irregularitiesLasers or Electrolysis (Tattoo Removal, and/or Laser Hair Removal)Treatment for cellulite, varicose veins, and stretch marksBody Shaping Treatments (Coolsculpting, Emsculpt)Scar Treatment and ReductionA cosmetic or reconstructive surgical consultationOther (not listed here)I'm not sure and need help figuring this part out.
Are you currently pregnant?*

YesNoThere is a possibility that I could be pregnant.Not Applicable
Are you currently breastfeeding?

YesNoNot Applicable
Are you currently under the care of a dermatologist, plastic surgeon, or aesthetics practitioner?

YesNo
If yes, please share the name and telephone number of your provider:
Please upload any orders or forms from your medical doctor:

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Why cover the whole bill if you don't have to? Upload the front and back of your insurance card here and we can see what we can get comped for you :)

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We want to put a face to your name. Please upload the front and back of your government-issued ID here:

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Medical History

We care about you...
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:
Do you have any allergies?*

YesNo
Please list your allergies:
Please list your Current Medications:
Please list Surgical Procedures & Dates of Each:
Healthy & Unhealthy Habits

No judgements, offering improvements upon request...
Exercise

Never1-2 days3-4 days5+ days
Eating habits/following a diet

I have a loose dietI have a strict dietI eat generally healthy, but I could make improvementsI don't have a diet plan
Alcohol Consumption

I don't drinkI am a social drinker (less than 5 drinks/week)1-2 glasses/day3-4 glasses/day5+ glasses/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Do you Vape?

YesNo
Are there any other elements or substances in your routine?

CaffeineMarijuanaMagic MushroomsCocaineMDMA and/or 2CBLSDMethamphetamineOther
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION TO THIRD PARTY PURSUANT TO HIPAA

This authorization indicates a disclosure of information pertaining to medical records and the release of official laboratory results/treatment to a third party for the intended medical reasons. I, the patient, allow Checkmate Health Strategies to release any/all results and reports in relation to my aesthetic healthcare plan to my primary care physician/medical doctor, surgeon, and/or the affiliates involved in my care.

I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form to only those agreed upon for my care.
CHECKMATE HEALTH STRATEGIES AUTHORIZATION TO GIVE MEDICAL CARE – CONSENT TO TREATMENT: I hereby voluntarily consent to treatment and care from all medical personnel contracted with Checkmate Health Strategies. I further consent to the performance of any diagnostic procedures, examinations, laboratory tests and rendering of medical treatment by Checkmate Health Strategies’ medical Providers and staff, as is necessary in the medical staff’s judgment. I understand that this consent will be valid and remain in effect as long as I am a patient at the clinic. *

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My Products

Deposit (Aesthetic Enhancements)Non-Refundable. Pay remainder at time of booking.

$75.00 Quantity

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Total

$0.00

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Personalized Care ♟ Aesthetics

Medical History

Healthy & Unhealthy Habits