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Date
*
Full Name
*
First
Last
Date of Birth
*
Age
*
Phone Number
Email Address
*
Address
Emergency Contact
*
Emergency Contact Phone
Primary Care Provider
What services are you interested in today? (Check all that apply)
Medical Weight Loss
Peptide Therapy
IV Hydration Therapy
Botox / Neurotoxins
Dermal Fillers
Chemical Peel
HydraFacial
Microneedling
Skin Rejuvenation
Hormone Optimization
Other Services
What are your primary goals?
Weight Loss
Increased Energy
Improved Skin Health
Anti-Aging
Facial Rejuvenation
Wellness Optimization
Stress Reduction
Other Goals
Describe your goals
Do you currently have or have you ever been diagnosed with:
Diabetes
High Blood Pressure
Heart Disease
Stroke
Cancer
Thyroid Disorder
Autoimmune Disease
Kidney Disease
Liver Disease
Blood Clotting Disorder
Depression/Anxiety
None
Other Medical Conditions
Please list all prescription medications, supplements, vitamins, and injections
Allergies
No Known Allergies
Medication Allergies
Food Allergies
Other Allergies
Current Weight (lbs.)
Height
Goal Weight (lbs.)
Have you previously used weight loss medications?
Yes
No
If yes, specify
Current Exercise Routine
Dietary Preferences/Restrictions
Have you received any of the following treatments?
Botox
Dermal Fillers
Chemical Peels
Microneedling
Laser Treatments
HydraFacial
None
Weight Provider currently
Date of Last Treatment
Current Skin Concerns
Fine Lines/Wrinkles
Acne
Hyperpigmentation
Sun Damage
Rosacea
Dryness
Skin Laxity
Other Skin Concerns
Are you currently pregnant?
Yes
No
Are you currently breastfeeding?
Yes
No
Client Signature
*
Date
Vital Signs – BP
Vital Signs – HR
Vital Signs – Weight
Vital Signs – BMI
Assessment Notes
Treatment Recommendations
Provider Signature
Date
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