Aesthetics - New Patient Intake Form - Integrated Health Clinic 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your full name and preferred name in the designated fields. This ensures that the clinic addresses you correctly.
3. Fill in the date and your age. This information is crucial for your medical records.
4. Indicate who referred you to the clinic, if applicable. This helps the clinic understand their referral sources.
5. Answer questions regarding previous injectable aesthetic procedures. If applicable, circle 'Yes' and provide details about the procedure and any complications.
6. Check any skin concerns that apply to you from the provided list. This assists in tailoring your treatment plan.
7. List any skincare products you currently use along with their brand names. This helps clinicians understand your skincare routine.
8. Review health-related questions carefully, checking any that pertain to your medical history.
9. Finally, provide any additional information or concerns you wish to communicate to the doctor before submitting the form.

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