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New Patient Form

Please fill out the form below and upload it 

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New Patient Form (1 of 3) 
How did you hear about us? Check all that apply:
Main Concern(s): Face, Neck & Skin
Main Concern(s): Body & Wellness
Main Concern(s): Female Health
Main Concern(s): Sexual Health
Skin type:
Previous procedures: Injectable
Previous procedures: Skin treatment
Previous procedures: Body
Previous procedures: Face/Neck tightening or lifting
Previous procedures: Vaginal/Pelvis
Previous procedures: Regenerative/Wellness

Past medical history and review of systems: 
(Please check all that apply)

Are you physically active?

Do you now have or have you ever had: if yes, please specify.

Constitutional (fatigue, poor sleep, low energy)?
Neurological problems: (seizures, headaches, weakness, paralysis)?
Psychiatric problems? Depression? Mania? Bipolar?
Head/Ear/Eyes/Nose/Throat problems?
Thyroid or glandular problems?
Cardiac (heart) problems? Palpitations? Chest pain? Irregular heartbeat?
Lung problems? Asthma? Short of breathe? COVID-19?
Breast problems? Mass? Lumpiness? Discharge? Pain?
Gastrointestinal problems (Gas, reflux, irritable bowel)?
Kidney or bladder disease? Stones? Infections? Blood in urine?
Liver problems, such as hepatitis?
Hematologic problems such as bleeding or anemia?
Diabete (insulin dependent/oral medication) or low sugar?
Musculoskeletal (bones, joints, muscles) problems?
Circulation problem (varicose veins, thrombosis, blood clots)?
Cancer or pre-cancerous conditions?
High blood pressure/low blood pressure/fainting spells?
Hernias in the abdomen?
Skin disorders (keloid, melanoma, acne, rash, cancers)?
Hair problem (hair thinning, balding, scarring)?
Gynecologic (fibroid, ovarian cyst, painful period)?
Vaginal looseness, difficulty orgasm, pain, decreased drive?
Urinary problems (if yes, fill out section on the next page)?
STD (HIV, gonorrhea , chlamydia, hepatitis, syphilis, warts)?
Genital herpes?
Oral herpes or cold sores?
Poor wound healing or frequent infections?
Any metal implants, such as metal IUD, metal plates or rods?
Problems with anesthesia (nausea, anxiety, allergic reaction)?
Other

Thank you!

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