Patient Intake · RN Aesthetics EMR

Personal information

First name *

Last name *

Date of birth *

Gender *

Phone *

Email *

Street address *

City *

Province *

Postal code *

Family doctor

Name of family doctor

Family doctor phone

Patient Intake

Current medications (name, dose, frequency)

Allergies (allergen and reaction)

Are you currently pregnant? *

Yes No

Are you currently breastfeeding? *

Yes No

Surgical history

Previous aesthetic treatments (what, when, where)

Any complications from previous treatments?

What are your treatment goals?

I confirm the information provided above is accurate and complete to the best of my knowledge.

I acknowledge the above statement *

Yes No