Microneedling Medical Intake Form

    1. First Name *

    2. Last Name *

    3. Address *

    4. Apartment / Suite (optional)

    5. Email *

    6. Phone # *

    7. Gender (select one) *

    8. Birthday *

    9. Emergency Contact Name & Phone Number *

    10. Were you referred by someone?

    11. What is your occupation? *

    12. Are you currently pregnant? *

    13. Any existing or recent illness? *

    14. Any recent hospitalization or surgery? *

    15. Please list the names of any medications you are taking: *

    16. Are you taking any of the following medications? *

    17. Do you have any of the following allergies or sensitivities? *

    18. Please indicate any other allergies: *

    19. Have you had any aesthetic procedures in the treatment area within the last 6 months? *

    20. Which of the following conditions apply to you? (check all that apply)? *

    21. Do you have medical insurance? *

    Cancellation Policy

    The appointment time you have chosen is the fee you will be charged.
    The ways you can reschedule or cancel your appointment are:
    1. Online through scheduling system or ("View My Appointments")
    2. By telephone (time-stamped) at 902-478-7393 up to 48 hours before your appointment.
    After this time passes your credit card is automatically charged or an invoice issued. Same applies to no-show appointments. Appointments must be paid before the commencement of your next treatment. Forms or requests (other than this one) are not monitored (e.g. e-mails or messages sent through Facebook or other social media sites will not be accepted as a cancellation request). Thank you.