Patient Intake Form - Medical Rejuvenation Centre

Name*

FirstLast

Phone*

Address

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Email*

Medical Card Number

Birth Date (M/D/Y)*

Weight

Height

How did you hear about us?*

Would you like us to send you information and updates in the future?*

Do you have any of the following medical problems? (Please specify by checking related box)*

Do you have any of the following skin problems?

Have you had any unusual reactions to anesthesia? (muscle weakness, breathing problems)*

Please list all medications you are currently taking*

Are you pregnant*

List past surgeries and date

Are you or have you ever been on Accutane?

If you answered 'yes' to the previous question - when did you stop taking Accutane?

Please list all Allergies*

Are you a smoker?

Are you planning a holiday in the sun?

What treatments are you interested in?*

Name

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