Patient Health Information Form

Fill out the form, or contact us to set up a consultation.

Name

Date of Birth

Gender

Female Male

Address

City

Postal Code

Phone Number

Email

What is the reason for your consultation today?

Migraine Hyperhidrosis Hyperactive Masseter / TMJ Platelet Rich Plasma PRP Alopecia Acne Other

Are you Pregnant or breastfeeding or Planning a pregnancy in the near future?

Yes No

Are you booked for facial, hair appointment or dental work after your treatment?

Yes No

Allergies / Sensitivities (Medication / Environment) Please Explain

Do you have a problem with the local freezing that is used by your dentist?

Yes No

Are you planning to travel soon?

Yes No

Date of Travel

Current Medication List (including Herbal / OTC)

Do you have history of:

Heart Disease Diabetes Hypertension Skin Cancer Epilepsy Bleeding Disorder Autoimmune Disease Other

Have you previously had: (Please list dates for those below)

Neurotoxin

Injectable Filters

Chemical Peels

IPL / Laser / Skin Tightening

Facial Surgery

Referring Physician

Date

Company

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