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Pampering
Massage
Nails
Euro Facial
Hair Waxing
Teeth Whitening
Laser
Laser Hair Removal
Tattoo Removal
Skin Enhancement
Skin Pigmentation
Skin
Botox®
Skin Consults
Clinical-Medical Facials
Chemical Peels
Products
Featured Spa Packages
Contact Us
Patient Intake Form
Home
About
Pampering
Massage
Nails
Euro Facial
Hair Waxing
Teeth Whitening
Laser
Laser Hair Removal
Tattoo Removal
Skin Enhancement
Skin Pigmentation
Skin
Botox®
Skin Consults
Clinical-Medical Facials
Chemical Peels
Products
Featured Spa Packages
Contact Us
Patient Intake Form
Home
About
Pampering
Massage
Nails
Euro Facial
Hair Waxing
Teeth Whitening
Laser
Laser Hair Removal
Tattoo Removal
Skin Enhancement
Skin Pigmentation
Skin
Botox®
Skin Consults
Clinical-Medical Facials
Chemical Peels
Products
Featured Spa Packages
Contact Us
Patient Intake Form
Home
About
Pampering
Massage
Nails
Euro Facial
Hair Waxing
Teeth Whitening
Laser
Laser Hair Removal
Tattoo Removal
Skin Enhancement
Skin Pigmentation
Skin
Botox®
Skin Consults
Clinical-Medical Facials
Chemical Peels
Products
Featured Spa Packages
Contact Us
Patient Intake Form
Patient Intake Form
First Name
Last Name
Middle Name
Date of Birth
Occupation
Address
City
State
ZIP
Email
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
What Year
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)
Botox
Tattoo Removal
Injectable Fillers (i.e. Juvederm, Radiesse, Voluma)
Laser Hair Removal
Facials
Permanent Makeup or Microblading
Microdermabrasions
Laser Resurfacing (i.e. Fraxel, Halo, CO2)
Chemical Peels
Photofacial/IPL/BBL
Microneedling with or without PRP
Waxing
Lash/ Brow Tinting
Electrolysis
Facial Cosmetic Surgery
None of the above
Which procedures are you interested in?
(Please check all that apply)
Botox
Tattoo Removal
Injectable Fillers (i.e. Juvederm, Radiesse, Voluma)
Laser Hair Removal
Facials
Permanent Makeup or Microblading
Microdermabrasions
Laser Resurfacing (i.e. Fraxel, Halo, CO2)
Chemical Peels
Photofacial/IPL/BBL
Microneedling with or without PRP
Waxing
Lash/ Brow Tinting
Electrolysis
Facial Cosmetic Surgery
None of the above
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.
Date
Do you now have, or have you ever had, any of the following? Please check all that apply:
Arthritis
Asthma
Blood Clots
Blood Pressure H/L
Broken/ Fracture Bones
Cancer/Chemo
Chronic Pain
Depression/ Anxiety
Diabetes
Digestive Disturbances
Dizziness
Easy Bruising
Epilepsy
Fainting
Fatigue/ Sleep Disorder
Fibromyalgia
Headaches
Heart Condition
Hepatitis
Herpes/Shingles
Implanted Medical Devices
Jaw Pain/TMJ
Lymphedema
Nail/Skin Fungus
Numbness/Tingling
Open Sores/Ulcers
Pacemaker
Permanent Makeup
Currently Pregnant
Currently Breastfeeding
Rashes
Sinus Problems
Spasms/Cramps
Sprains/Strains
Spinal/Bone Problems
Stroke
Swelling
Tattoos
Varicose Veins
Warts
Wear Contacts
None of the Above
Do you have a history of Keloids or Hypertrophic Scars
Yes
No
Do you Tan?
Yes
No
How?
Direct Sun
Tanning Bed
Spray Tan
Are you under the care of a physician?
Yes
No
Last Visit (Apprx.)
Dr. Name
Are you allergic to
Milk
Apples
Grapes
Aloe Vera
Aspirin
Hydroquinone
Kojic Acid
Pineapple
Other Allergies
Allergic to any medications and/or chemicals?:
Do you use/take
Accutane
Aspirin
Blood thinners
Retin-A
Other Rx skin topical products
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
If yes, when?
What products are you currently using on your skin?
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