Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Please check box below, if a message can be left. at this number.
Occupation
Email
*
Date of Birth
*
Health Card Number
*
Gender Identification
Pronouns
If you feel comfortable, please check your pronouns below.
Family Physician
*
Medical Conditions
*
Please check all that apply.
If you answered yes to Cancer, or selected Other, please explain further in the space provided below.
Are You Pregnant or Breastfeeding?
*
Are You Taking Hormones or Birth control Pills?
*
Let Us Know
*
How did you hear about our clinic?
If you selected, Other please specify.
I am Interested In the following treatments
*
Please check all that apply.
If you selected, Other please specify.
Skin Diva Can Help:
What area/s are you interested in treating, or have more questions about? Please check all that apply.
If you selected, Other please specify.
May we contact you to remind you about upcoming or missed appointments?
*
May we contact you regarding new services, products and procedures?
*
Preferred Method Of Contact
If you selected Yes to either of the above 2 questions, how would you like to be contacted?
Please provide the information of your preferred method of contact.
I agree that the information listed above is to the best of my knowledge, truthful, and accurate. I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
*
