Patient Intake FormFill out our Patient Intake Form to provide us with essential information about your health history and current concerns. Name * First Name Last Name Birthdate * MM DD YYYY Phone Number (Home) * Country (###) ### #### Phone Number (Mobile) * Country (###) ### #### Home Address * City Name of family physician or referring doctor (optional) First Name Last Name Email * Request for expressed consent to send you messages. To comply with Canada's Anti-Spam Legislation we need your consent to receive electronic communications from Kristy Jones, RN and Dr. Nasim Abedi's team. This communication will be via email and text message in the form of welcome letters, appointment confirmations and changes, follow up messages, and approximately 12-15 yearly newsletters, promotions, events and other information regarding our services, procedures and skin care products. By choosing yes you are granting us permission to send you electronic messages and emails and understand there are inherent risks and limitations with this type of communication. Your contact information will not be shared with any 3rd parties. You can unsubscribe at any time by clicking the unsubscribe button on our newsletters. * Yes, I would like to receive electronic communications and emails No, please do not send me information electronically Would you like to enroll in the rewards programs offered through the companies that we purchase our injection products from? Yes, please sign me up via my email address No, I do not wish to participate or would like more information PATIENT CONCERNS Check All That Apply Volume Loss Chin Fat Neck Lines Aging Skin Wrinkles Cheek Enhancement Excessive Sweating Lip Enhancement Defined Jawline Aging Hands Skin Care Concerns Are you currently on or have you taken any of the following medication in the last 6 months? Accutaine Retin-A or Retinol Hydroquinone None if the above Have you taken gingko, asa, advil, ibuprofen, red wine, fish oils in the last 10 days? Yes No Please list any current medications, herbal supplements and hormone therapy. Please list any allergies to medication, environmental or skin sensitivities. List all your medical conditions List all of your previous surgeries Check All That Apply Glaucoma Contact Lenses Nasal Allergy Symptoms Sinus Infection Eye Allergy Symptoms Stroke/ Dizziness Chest pain/ Angina/ Palpitations High Blood Pressure Heart Condition Autoimmune Disorder Epilepsy Headache Neurological Disorder Treatment by a Psychiatrist Diabetes Thyroid Disease HIV/AIDS/ Hepatitis, Cancer, or IV Drug Use Cold Sores/ Shingles Cystic Acne Rosacea Melasma Do you have an allergy to bees or wasps? Yes No Are you pregnant or breastfeeding? Yes No Have you been to the dentist in the last 2 weeks? Yes No Have you had any kind of infection in the last 2 weeks (including head cold, urinary tract infection, skin infection) Yes No COSMETIC PROCEDURES Have you had any of the following treatments? None Botox, Xeomin, Dysport, Nuceiva Juvederm, Restylane, Belotero, Teosyal Permanent Filler Facial Implants Radiesse, Sculptra Chemical Peels Laser Treatments Microneedling Cosmetic Tattooing If yes to any above please list approximate dates. If yes to any above, were your expectations met? I have read and will follow to the best of my abilities any and all instructions. I will let my practitioner know if I start any new medications, skin care products, become pregnant or have undergone any treatments at other facilities that could possibly affect the outcome of my treatment program with Dr. Nasim Abedi or Kristy Jones, RN. I understand there is a minimum of 24 hours notice to cancel or reschedule an appointment. There is a $100 late cancellation fee and a credit card will be required for re-booking and no show appointments. * By checking this I agree with the above statement No, I would like to be contacted to clarify my information Date MM DD YYYY Thank you!
