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Ft. Lauderdale Office
Miami Office
Contact

Contact

[email protected]
Miami Office
(305) 882 - 9439
18157 Biscayne Blvd, Aventura, FL 33160
Ft. Lauderdale Office
(954) 719-7123
464 N. Federal Highway Ft. Lauderdale, FL 33301

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Ft Lauderdale

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Ft Lauderdale

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Ft. Lauderdale Office
Miami Office
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Home
Treatments
About
Before and After
Book an Appointment
Testimonials
Shop
Blog
Ft. Lauderdale Office
Miami Office
Contact

Contact

[email protected]
Miami Office
(305) 882 - 9439
18157 Biscayne Blvd, Aventura, FL 33160
Ft. Lauderdale Office
(954) 719-7123
464 N. Federal Highway Ft. Lauderdale, FL 33301

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New Patient Form

Please fill out the form below or download a fillable PDF form by clicking here to submit to us via email to [email protected]

Today's Date

First Name

Last Name

Home Address

City

State

Zip Code

Country

Age

Date of Birth

Martial Status

Single Married

Sex

Male Female

Email (For Office Use Only)

Home Phone Number

Cell Number

Work Number

Employer

Occupation

How did you hear about us?

If referral, who referred you to us?

Name of Emergency Contact

Relationship

Emergency Home Number

Emergency Cell Number

Reason for today's Visit

Have you had Botox® treatment in the past?

Yes No

If yes, how long ago have you had Botox?

Have you had facial fillers (such as Juvederm® , Restylane, Perlane, Voluma™) in the past?

Yes No

If yes, how long ago have you had filler?

Are you interested in learning more about: (check all that apply)

Botox Botox for headaches Botox for sweating Filler Laser for brown spots Laser for blood vessels PRP for thin hair PRP for skin rejuvenation Chemical peels Medical grade skincare Skin tightening Laser resurfacing

Do you clench your teeth?

Yes No

Do you have TMJ pain?

Yes No

Do you get frequent headaches?

Yes No

Consent

I, the undersigned (patient or legally responsible party), authorize treatment to be rendered by the doctor and his/her staff, and I assume all financial responsibility for treatment given, services rendered and all associated costs incurred as a result of my treatment. I acknowledge that all the information contained herein is true and correct and give my permission to verify any of the information provided. I, the undersigned (patient or legally responsible party), have reviewed the HIPAA Privacy Policy Notice available in the office of The Beauty Clinic.

Please sign with your name

Signature Date

Name of primary doctor

Phone Number of Primary Physician

Are you under a physician's care for any medical condition?

Yes No

If yes, please explain why

Have you ever been hospitalized or had a major operation?

Yes No

If yes, please explain reason for hospitalization

PLEASE LIST ALL THE MEDICATIONS, PILLS, OR DRUGS THAT YOU ARE TAKING

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?*** (REQUIRED)

Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa drugs Local Anesthetics \Other allergies

Other allergies

Do you drink alcohol?

Yes No

If yes, how much/how often do you drink alcohol?

Do you smoke or use tobacco?

Yes No

If yes, how much/how often do you smoke?

WOMEN ONLY: Are you pregnant or trying to get pregnant?

Yes No

If pregnant, how many weeks?

Are you taking oral contraceptives?

Yes No

Are you nursing?

Yes No

In order to safely treat you and make proper diagnoses, it is important that we know your medical conditions. Do you have, or have you had, any of the following?*** (REQUIRED)

AlDS/H IV Positive Alzheimer's Disease Anaphylaxis Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pain Cold Sores/Fever Blister Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Lung Disease Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pace Maker Heart Trouble/Disease Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Mitra! Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/GI Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors of Growth Ulcers Venereal Disease Weak Immune System Yellow Jaundice

Have you ever had any serious illness not listed above?

Yes No

If yes, please explain any serious illness:

Do you need to be premedicated before dental treatment?

Yes No

If yes, please explain premedications:

Acceptance

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing inaccurate information can be dangerous to the health of the patient. It is my responsibility to inform this office of any changes in my medical status.

*SIGNATURE OF PATIENT (or Parent/Guardian): Please Sign by Typing Your Name

Date of Signature

Yes, you can look natural with Botox and Fillers! We’ve helped thousands of people look refreshed and rejuvenated with injectables.

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PRF EZGel Biofiller

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New Patient Form

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