Patient Intake Form

Name

Birthday

Phone Number

Texting Policy

By providing my phone number, I consent to receive SMS text messages from Meesha Aesthetics for appointment reminders, and general two-way communication. Msg frequency varies. Msg&data rates may apply. Reply HELP for support. Reply STOP to opt out. Terms and Conditions + Privacy Policy here: https://www.botoxbymeesha.com/faq

Address

Email Address

Would You Like to Subscribe To Our Newsletter?

Yes No

How'd You Find Us?

Please List Any Allergies

Please List Any Medications

Please answer yes or no to the following. Do you have:

Are you currently being monitored for any on going medical issues?

Yes No

If yes, Elaborate:

A disease that affects your muscles and nerves (ALS or Lou Gehrig's Disease) myasthenia graves or Lamber-Eaton Syndrome?

Yes No

Have you ever had a reaction to 'Botox'?

Yes No

Any Infection or muscle weakness in treatment area

Yes No

Skin cancer in treatment site?

Yes No

Bleeding problems / history of Blood Clots

Yes No

Had surgery or plan to have surgery on your face?

Yes No

if yes, what?

Have you used Accutane in the last 12 Months?

Yes No

A cutaneous auto-immune disease (Scleroderma, active lupus) and / or are you on any immunosuppressants?

Yes No

Any history of keloid scarring?

Yes No

Are you pregnant / breastfeeding or planning to become pregnant in the next three months?

Yes No

Do you get Oral Herpes?

Yes No

If you answered yes above, please elaborate here:

Have you read our Meesha Rules?

Yes No

The Meesha Rules

When your results are amazing, can we share your pic:

On Social Media‎ In person to other patients‎ Not at all‎

I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. I understand that if any changes occur in my medical history / health, I will report it to the office as soon as possible. I have read and understand the above medical questionnaire. I acknowledge that all answer have been recorded truthfully and will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form.

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The Area Below This Text Box is For Our Team, You, our super awesome client, can ignore it! Scroll all the way to the Send button!

According to this client's health history, he/she is approved for Neurotoxins, Dermal Filler, Kybella Ultrashape, CO2re Fractional Laser / Vaginal Rejuvenation, Skin Tightening, Scleratherapy, PDO Threading, Chemical Peels, Microneedling, Latisse and / or Profound unless noted here:

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MD Signature // Date:

Kristen Shimp CRNP