Patient Intake Form

Date*
Date Format: MM slash DD slash YYYY
Patient Name*
First Last
Address*
Street Address Address Line 2 City State ZIP
Email*
Phone*
May we leave a message?*
- Yes
- No
Preferred method of communication from our office? (please check all that apply)*
- Text
- Phone Call
- Email
Date of Birth*
Date Format: MM slash DD slash YYYY
Age*
Sex*
- Male
- Female
Marital Status
Occupation
Employer
Emergency Contact Name
Relationship
Emergency Phone
How did you hear about us?
Reason for consultation
Please describe your skin and skin concerns (please check all that apply)
- Thick
- Thin
- Saggy
- Firm
- Fine Lines
- Wrinkled
- Aging
- Dry
- Normal
- Oily
- Combination
- Large Pores
- Sun Freckles
- Uneven/Blotchy
- Active Acne
- Acne Scars/Scars
- Blackheads/Whiteheads
- Cysts
- Dark Spots/Patches
- Scaling/Flaking
- Broken Capillaries
- Sallow
- Puffiness
- Rosacea
- Dehydrated
- Eczema or Psoriasis
- Dark Circles/Eyes
Other
Are there any other treatments/conditions you are interested in hearing more about? (please check all that apply)
- Longer lashes
- Dark spots/hyperpigmentation
- Excessive sweating
- Thinning hair
- Vaginal rejuvenation
- Scar treatment
- Double chin
- Fine lines and wrinkles
- Skin laxity
- Medical grade skin care
- Acne
- Hair removal
Other
What is important to you when deciding on a skin treatment?

Cancellation/No Show Policy*
- I agree to the Cancellation/No Show Policy below.
We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment within 24 hours, you may be preventing another patient from getting a much-needed service. Conversely, the situation may arise where another patient fails to cancel, and we are unable to schedule you for an appointment. If an appointment is not canceled at Empower MedSpa at least 24 hours in advance you will be charged a fifty-dollar ($50) fee.
Your Name*
Entering your name here acts as your signature
Date of Submission*
Date Format: MM slash DD slash YYYY

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