First Name *

Last Name *

Date of Birth *

Address *

City *

State *

Postal code *

Cell Phone *

Home Phone

Work Phone

Email *

Monthly Specials & Events Notification Consent. Circle all that apply. *

Telephone

Text Message

Appointment Notification Consent. Circle all that apply. *

Telephone

Text Message

What is the nature of your visit? *

Occupation *

How did you hear about us? If Referred by a client, please list their name. *

Emergency contact name and phone number *

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TERMS

24 HOUR CANCELLATION POLICY

Appointments that are cancelled with less than 24 hour notice will be charged 50% of the service. "No-Show" appointments will be charged 100% of the service. Medical appointments with Same Day Cancellations/No-Show will be charged $100. The credit card that is used to hold the appointment will be charged in accordance to the above Cancellation Policy.

PAYMENT POLICY

Payment is due in full upon completion of service.

Do you understand that every procedure/operation is followed by a period of healing before the tissue returns to normal and the final result is apparent? *

Yes

Do you understand that the objective of any cosmetic procedure is an improvement, not perfection? *

Yes

Patient Signature (Terms) *

Clear

Parent/Guardian Signature (If under the age of 18 years)

Clear

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Date (Terms)

SKIN TYPING MATRIX

Please answer the following questions by choosing which best describes you. Your clinician will total your score during the consultation.

My ethnic origin is closest to: *

My eye color is: *

My natural hair color at age 18 was: *

The color of my skin that is not normally exposed to sun is: *

If I go out into the sun for an hour or so without sunscreen and have not been out in the sun for weeks, my skin will: *

If you sustain an injury to your skin such as a cut, burn, or bruise, how long does it take to fully resolve without any hyperpigmentation? *

If you get an insect bite, are you left with a brown spot? *

Do you ever get "cold sores" or "fever blisters"?

WEIGHT LOSS INTAKE FORM

At what age did you first start having a weight loss problem? *

Weight at age 21 *

Highest weight? *

Current weight? *

Has weight come on? *

Yes

If Yes:

Gradually over the years

Suddenly over certain periods of time

What was going on at that time? *

What behaviors and circumstances contribute to your weight? *

List your previous attempts to lose weight. What specific aspects of these attempts worked for you and what didn’t? *

Have you ever been able to lose weight and keep it off? Do you typically regain your weight after losing it? *

SURGICAL HISTORY

If applicable, list any Bariatric procedures you have had in the past (gastric sleeve, gastric bypass, lap band, etc).

1a. Procedure

1b. Date

1c. Weight prior to procedure

1d. Lowest weight after procedure

2a. Procedure

2b. Date

2c. Weight prior to procedure

2d. Lowest weight after procedure

Have you had your yearly bariatric vitamin labs drawn? (if applicable)

Yes

Do you taI‹e your bariatric vitamins daily? (if applicable)

Yes

EATING PATTERNS

Do you struggle with cravings? *

Yes

Do you struggle with feelings of fullness? *

Is there a time of day when it is more difficult to avoid overeating or to avoid less optimal food choices? *

If YES, when?

Is food volume a problem? *

Are your portions large? *

Do you go back for seconds? *

Who cooks most in your household? *

Who grocery shops in your household? *

FOOD RECALL

Which meals do you eat nearly every day? Give times and typical contents of each meal.

Mid-morning snack?

Breakfast?

Lunch?

Mid - afternoon snack?

Dinner?

Evening snack?

PERTINENT MEDICAL HISTORY

History of pancreatitis? *

History of seizures? *

History of liver disease? *

History of gout? *

If yes, when was the last flare?

Are you on any medications for gout? If Yes, what are they?

Personal family history of medul!ary thyroid cancer? *

Is there any chance of pregnancy?

Pregnancy prevention method?

Are you currently taking narcotics for pain control? *

History of kidney disease? *

History of kidney stones? *

History of glaucoma? *

INTAKE FORM

Is there one thing you could do that would make a large difference in helping you to manage your weight long term? *

If yes, what is it?

Why do you think you haven't made that change? *

How do you foresee my role in helping you in your efforts to reduce and maintain your weight long term with an individualized and sustainable long-term plan? *

What is motivating you currently to focus on management of your weight? *