Patient Intake Form - Creekside Day Spa

May we contact you by email?

Yes No

Primary Contact Phone #

Secondary Contact Phone #

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relation

Have you been a patient of Dr. Michael B. Stevens? If yes, what year?

Yes No

Have you been seen by Kendel, with Dr. Stevens’ office for Skin Health?

Yes No

Would you be willing to give CreekSide/ Topograph permission to use your name, biographical information, personal story and photographic likeness in all forms of media?

Yes No

How did you hear about us?

Reason for the visit

Which procedures have you had in the past?
(Please check all that apply)

Which procedures are you interested in?
(Please check all that apply)

Authorization for Treatment and Financial Disclosures
I authorize treatment for the person named on this form and agree to pay all charges for such treatments. I agree to pay all charges for me and members of my family at time of service. I authorize the release of any information regarding my treatment needed to resolve any billing dispute.

If unable to keep an appointment, CreekSide requires a 48 hour notice for any single treatment, and 72 hour notice for any two or more treatments. If CreekSide is not notified prior to your appointment, there will be a $50.00 service charge per treatment. As a friendly reminder we have a no children and no cell phone policy. (NO EXCEPTIONS) Thank you for your understanding and consideration.

Do you now have, or have you ever had, any of the following? Please check all that apply:

Do you have a history of Keloids or Hypertrophic Scars

Yes No

How?

Direct Sun Tanning Bed Spray Tan

Are you under the care of a physician?

Yes No

Are you allergic to

Allergic to any medications and/or chemicals?:

Do you use/take

Other Rx medications (Please list):

Have you been on any antibiotics in the last 10 days? If yes, when was your last dose?

Have you recently had a

Chemical Peel Laser Resurfacing Botox/Fillers

What products are you currently using on your skin?

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