Patient Intake Form

Welcome to our Wellness Clinic! We are thrilled to have you join us on your journey to enhanced health and well-being. Please fill out the information below to ensure we have everything we need to provide you with the best care possible.

Personal Information

Gender *

Male Female

Preferred Method of Contact *

Phone Email Text Message

Emergency Contact Information

Relationship to You *

Health and Wellness Screen

Medical History

Please answer the following questions truthfully and thoroughly. Your safety is our top priority.

1. Are you currently pregnant or breastfeeding? *

Yes No

2. Do you have a history of any of the following conditions? *
(Check all that apply)

3. Have you ever had Botox®, Dysport®, Xeomin®, or other neurotoxin injections before? *

Yes No

If yes, date of last treatment *

Any complications? *

4. Are you currently taking any of the following medications or supplements? *

Please list all current medications, vitamins, and supplements *

5. Do you have any allergies (including medications, foods, or topical products)? *

Yes No

If yes, please list *

Aesthetic Goals & Treatment Areas

What areas are you interested in treating? *

Have you had any cosmetic treatments in the past 6 months (laser, filler, peel, etc.)? *

Yes No

If yes, please list *
*

Please provide a brief overview of your health and wellness goals for visiting our clinic *

Lifestyle Information

Do you smoke? *

Yes No

Do you consume alcohol? *

Yes No

Exercise Frequency *

Consent and Agreement

I consent for photographs and/or video images to be taken of me by Wellness Rejuvenation Medical Center or a representative. I understand the images will be a part of my medical record and may be used for purposes of medical teaching or training or for marketing purposes (website, print, digital or social media).

By consenting to photographs and/or video images I understand I will not be compensated from any party. Although photographs and/or video images will be used without identifying information such as name, I understand it is possible someone may recognize me.

I further acknowledge that my participation is voluntary and agree that use of any photographs and/or video images confers no rights of ownership or royalties whatsoever.

I authorize the use of photographs and/or video images: (please initial indicating YES or NO below)

For educational purposes (medical teaching or training), *

Yes No

For marketing and advertising purposes *

Yes No

At my request, my photographs and/or video images will only be used as part of my medical record. *

Yes No

By signing below, I acknowledge that I am voluntarily receiving wellness treatments at this clinic. I understand these services support overall health and are not meant to diagnose, treat, or cure medical conditions. I agree to update the clinic on any health changes and consult a healthcare provider for specific concerns. I release Wellness Rejuvenation Medical Center, its staff, and affiliates from any related liability. I understand this consent and may withdraw it anytime in writing to Wellness Rejuvenation Medical Center or by completing a new form.

Thank you for taking the time to complete this form. We look forward to assisting you on your path to optimal wellness!