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- Weight Management Screening
- New Patient Intake
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Services
Financing
Reviews
Baddies
Patient Forms
- Weight Management Screening
- New Patient Intake
Book Appointment
Call Now

Reviews
Baddies

Reviews
Baddies

Book Appointment

Medspa Patient Intake

About you

Section A · 1 of 8

Full legal name *

Date of birth *

Sex assigned at birth *FemaleMaleOther / prefer not to say

Mobile phone *

Email *

Emergency contact (name and phone) (optional)

Primary care doctor (name and phone) (optional)

Treatments you are interested in

Section B · 2 of 8

Which treatments are you interested in? Check all that apply. *Wrinkle relaxer (Botox, Dysport, Xeomin, Daxxify, Jeuveau)Dermal filler (Juvéderm, Restylane, RHA, or similar)Collagen stimulator (Sculptra or Radiesse)PRP or PRF for face or under-eyesPRP for hair lossKybella (double-chin injection)MicroneedlingChemical peelLaser, IPL, or radiofrequency skin treatmentNot sure yet. I would like a recommendation

Which areas would you like to treat, and what bothers you about them? *

What result are you hoping for? (optional)

Do you have a wedding, photos, travel, or another important event in the next 2 weeks? *Bruising and swelling can last up to 2 weeks.YesNo

What event, and when? (optional)

Past cosmetic treatments

Section C · 3 of 8

Have you had any of these before? *Wrinkle relaxer (Botox or similar)Hyaluronic acid fillerSculptra or RadiessePermanent filler (silicone, Bellafill/PMMA, or filler you are not sure about)PRP or PRFLaser, peel, or microneedlingFacial cosmetic surgery, implants, or threadsNone of these

When was your last wrinkle relaxer treatment? *

When was your last filler or collagen stimulator treatment?

When was your last filler or collagen stimulator treatment? *

Where was it done, which areas, and which products if you know? (optional)

Have you ever had a problem after a cosmetic treatment? *For example: drooping eyelid or brow, lumps, infection, skin turning white or dusky, or vision changes.YesNo

What happened, and how was it treated?

Health conditions

Section D · 4 of 8

Check anything that applies to you now or in the past. *Myasthenia gravis, ALS, Lambert-Eaton syndrome, or another nerve or muscle diseaseBell’s palsy or facial nerve weaknessAutoimmune disease (lupus, rheumatoid arthritis, scleroderma, or similar)Bleeding or clotting disorder, or you bruise very easilyLow platelets or a platelet disorderAnemiaCancer, now or in the pastHepatitis B or C, or HIVWeakened immune system or organ transplantDiabetesHeart disease, heart attack, or strokeCold sores (oral herpes)Keloids or thick raised scarsRosacea, eczema, psoriasis, or active acneDry eye, droopy eyelid, or recent eye surgeryNone of these

Other conditions or past surgeries (optional)Mention any other conditions or past surgeries

Safety questions

Section F · 6 of 8

These questions screen for medical reasons a treatment may not be safe. Answer as accurately as you can. “Not sure” is a fine answer.

Do you have an active infection, cold sore, open wound, or rash in or near an area you want treated? *YesNo

Have you ever had an allergic reaction to Botox, Dysport, Xeomin, or another botulinum toxin? *YesNoNot sure

Are you allergic to cow’s milk protein? *YesNoNot sure

Have you ever had a severe allergic reaction (anaphylaxis) to anything? *YesNoNot sure

Medications and allergies

Section E · 5 of 8

Do you currently take any of these? *Blood thinner (warfarin, Eliquis, Xarelto, Plavix, or similar)Aspirin, ibuprofen, naproxen, or other anti-inflammatory pain relieversFish oil, vitamin E, ginkgo, garlic, or turmeric supplementsPrednisone or another steroid pill, or a medicine that suppresses the immune systemRetin-A, tretinoin, or another prescription retinoid creamAn antibiotic right now (especially gentamicin, tobramycin, or similar)Ozempic, Wegovy, Mounjaro, Zepbound, or another weight-loss injectionNone of these

List all prescription medications (with doses), vitamins, and supplements. Write “none” if you take nothing. *Write “none” if you take nothing.

List any drug, food, or latex allergies. Write “none” if you have none. *Write “none” if you take nothing.

Lifestyle and expectations

Section G · 7 of 8

Do you smoke or vape nicotine? *YesNo

Alcohol in a typical week *

Which statement fits you best? *I want a natural, subtle improvementI want a noticeable changeI want a dramatic change that fixes something that really bothers me

May we take before-and-after photos for your medical record? *Photos for your chart are kept private. We will never use them for marketing without separate written permission.YesNo

California requires a brief medical exam before injectable treatments. Ours is done by a short video call with the provider before your appointment. Can you complete one? *Yes, I can do a short video call before my appointment

Best days and times for the video call *

During your video consult, the provider may use an AI scribe. It listens to and records the conversation to draft the visit note, which the provider reviews and corrects. The recording and note are kept confidential as part of your medical record. Do you consent? *You can say no and still have your consult. You can also change your mind at any time during the visit.Yes, I consent to the use of an AI scribe during my consultNo, I do not want an AI scribe used

Anything else you want the doctor to know? (optional)

Consent and signature

Section H · 8 of 8

Treatment decision *

I understand Snapglam Med Spa reviews this questionnaire to decide whether treatment is medically appropriate for me, that he may approve, limit, or decline any treatment, and that submitting it does not guarantee treatment.

Side effects *

I understand common side effects include bruising, swelling, redness, tenderness, headache, and asymmetry. Wrinkle relaxers can cause a temporary droopy eyelid or brow. Fillers can cause lumps and, rarely, blockage of a blood vessel that can damage skin or vision. PRP and microneedling can cause soreness, bruising, and rarely infection.

When to contact the office *

After treatment I will contact the office right away for increasing pain, skin turning white, blue, or dusky, signs of infection, or a drooping eyelid. I will call 911 for any vision change, trouble swallowing, breathing, or speaking, or spreading muscle weakness.

Healthy eating and activity *

I understand cosmetic results vary, are not permanent, may need touch-ups, and are not covered by insurance.

Accuracy of answers *

My answers are true and complete to the best of my knowledge. I will tell the office before treatment if my health, medications, or pregnancy status change.

Type your full name as your signature *

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