Patient Form Patient Form Step 1 of 2 50% Name(Required) First Last Birthday(Required) MM slash DD slash YYYY Height:(Required) Example: 5 ft 4 inWeight:(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Preferred PharmacyPharmacy Name: Pharmacy Phone Number: Emergency ContactEmergency Contact Name(Required) First Last Emergency Contact Phone #:(Required)Relationship to Patient(Required) How did you hear about us?(Required)Not SureFriendFamilyFacebookGoogleTwitterInstagramOther ARE YOU CURRENTLY PREGNANT, LACTATING, OR TRYING TO GET PREGNANT?(Required) No Yes Medical History(Required) Diabetes Hypertension Endocrine Problems (thyroid, etc.) Eating Disorder Abnormal Bleeding Anemia Cancer Cold Sores Eczema Hair Loss Heart disease HIV Liver Disease Skin Disease Stroke Osteoporosis or recent fractures Depression Bariatric Surgery Plastic Surgery (liposuction, tummy tuck) Kidney Compromise/Disease Lung conditions (emphysema, COPD, etc.) Addiction to substance/treatment Psychiatric diagnostic/treatment None of the above Please list any previous surgeries or hospitalizations (Please include the date of surgery/hospitalization as well as any complications/notes) If none, please write none:HiddenPLEASE LIST ANY OTHER HEALTH RELATED CONDITIONS OR CONCERNS NOT PREVIOUSLY IDENTIFIED: PLEASE LIST ANY CURRENT MEDICATIONS (ORAL AND/OR TOPICAL) AND/OR SUPPLEMENTS:(Required) ALLERGIES TO MEDICATIONS, LATEX OR ANY OTHER KNOWN ALLERGIES:(Required) HAVE YOU EVER HAD A FULL SKIN EXAM BY A DERMATOLOGIST?(Required) No Yes HAVE YOU EVER HAD ANY SKIN REJUVENATION TREATMENTS BEFORE (IPL, PROFRACTIONAL, LASER RESURFACING, ETC.)?(Required) No Yes IF SO, PLEASE EXPLAIN HAVE YOU EVER HAD ANY COSMETIC INJECTABLE? (BOTOX, DERMAL FILLER, ETC.)(Required) No Yes WHEN WAS THE LAST TIME? HAVE YOU EVER HAD ANY FACIAL SURGERIES?(Required) No Yes DO YOU SMOKE?(Required) Yes, currently Yes, in the past No, never DO YOU DRINK ALCOHOL?(Required) Yes, currently Yes, in the past No, never IF YES, HOW MUCH/HOW OFTEN? DO YOU USE ANY ILLEGAL DRUGS?(Required) Yes, currently Yes, in the past No, never DOCUMENTATION(Required) I authorize Westlake Aesthetics & Wellness to take photographs of me throughout the duration of my treatments in order to help document the progress of my treatments. PROMOTIONAL I consent to Westlake Aesthetics & Wellness using any photos taken for promotional and/or marketing purposes. If there was something you could improve about your skin/body/general health, what would it be? CONSENT(Required) By checking this box I agree to signing this New Patient Form electronically SIGNATURE(Required) Section Break Δ
