Intake Form

Please fill in this form after making an appointment with RN Aesthetics.

First Name *
Last Name *
Date of Birth *
Gender *
Address (Address, Province, Postal Code) *
Phone Number *
E-mail *
Name of Family Doctor
Family Doctor Phone Number
List any significant medical conditions you have. example: Diabetes, Autoimmune Disorders, etc

Have you ever had or currently being treated for, check all that apply.

Other (please specifiy)
Allergies:
Are you on any medications? If so, please specify:

Have you ever undergone any surgical procedures or had any significant injuries?

 *
If yes, please provide details

Are you pregnant or trying to become pregnant?

 *

Are you currently breastfeeding?

 *

Have you ever received any of the following treatments? Check all that apply:

 *
Other (Please Specify):
Date of last treatment listed above:

Have you ever had any complications or adverse reactions from previous aesthetic treatments?

 *
If yes, provide details
What are you primary concerns or goals for seeking aesthetic treatments? *
Consent and Agreement: By signing below, I acknowledge that the information provided on this form is accurate and complete to the best of my knowledge. I understand that it is essential to provide honest and accurate information to ensure the safety and effectiveness of any aesthetic treatment I may receive. (Please write your full name here) *
Date Signed *