Med Spa Intake Form
Please complete this form to help us provide you with the best care.
1/7
12 %
Visit Type
Please select whether this is a new patient visit or a follow-up appointment.
New Patient
First-time visit to our med spa. We'll need to collect your complete medical history.
Follow-Up
Returning patient for a follow-up appointment. We'll focus on your current treatment.
2/7
26 %
Basic Information
Please provide your personal information and medical history.



Drag & Drop Images Here
Please upload a photo or scan of your photo ID (eg. driving license or passport)
Drag & Drop Images Here
Please upload a full length photo of yourself which was taken in the last 4 weeks
Emergency Information
3/7
48%
Medical History
Please answer the following questions about your medical history.

Any medical problems (ex: high blood pressure)?*

Please explain:*

Any previous surgeries?*

Please explain:*

Do you take any medications or supplements?*

Please explain:*

Any allergies?*

Please explain:*
Allergy Reaction Action

Do you consume alcohol, tobacco, or recreational drugs?*

Please explain:*

Any personal history of autoimmune, neurological, or blood disorders?*

Please explain:*

Are you pregnant or breastfeeding?*

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4/7
62 %
Treatment Selection
Please select the treatment(s) you're receiving today.
Aesthetics
Weight loss
HRT (hormone replacement therapy)
Regenerative medicine
Peptides
IV infusion
Sexual Wellness
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5/7
71 %
Treatment-Specific Questions
Please answer the following questions for each selected treatment.
Sexual Wellness
Sexual Wellness

Treatment-Specific Questions

Please answer the following questions for each selected treatment.

Primary Concerns*

Please select all that apply:

Medical History

Do you have diabetes?*

Do you have heart disease?*

Do you have high blood pressure?*

Do you take blood thinners?*

Are you currently on hormone therapy?*

Previous Treatments*

Have you tried any treatments for sexual wellness concerns in the past? If so, please describe:

Goals*

What are your goals for sexual wellness treatment?

Additional Information*

What are your goals for sexual wellness treatment?

IV infusion
IV infusion

Treatment-Specific Questions

Please answer the following questions for each selected treatment.

Dehydration issues?*

Nutritional deficiencies?*

Current energy levels:*
Goals for IV therapy:*
Aesthetic
Aesthetic History

Any previous aesthetic treatments in the past?*

What areas are you looking to enhance or treat?*

Have you received any of the following treatments in the past?*

What is your primary reason for today's visit?*

Do you have any events, trips, or plans in the next 2 weeks?

Skin & Lifestyle

Are you currently using any of the following?*

Do you use tanning beds or have had recent sun exposure?*

On a scale of 1-10, how would you rate your current skin confidence?*

Weight Loss
Weight Loss

Medical Conditions*

Please select all medical conditions that apply to you.

Exercise Routine *

Primary Reason for Starting GLP-1 Therapy *

Previous Weight Loss Attempts

Please select all that apply: *

Weight loss goals: *

Commercial Product History

Please indicate if you have previously used a commercially available GLP-1 medication (e.g., Zepbound, Mounjaro, Ozempic):*

Rationale for Compounded Medication

Check all that apply. These will guide your personalized formulation:

FORMULATION MODIFICATIONS *

ADDITIVES REQUIRED FOR SYMPTOM MANAGEMENT *

DOSING & ADMINISTRATION CUSTOMIZATION *

OTHER PATIENT-SPECIFIC FACTORS *

HRT (hormone replacement therapy)
Hormone Replacement Therapy

Hormone Use History *

Duration and dosage: *

Symptoms/Reasons for Visit *

Please check all that apply

Upload Lab Results *

Click or drag PDF here
Regenerative medicine
Regenerative medicine

Primary Reason for Seeking Stem Cell/Exosome Therapy

Please select all that apply:

Previous Therapy

Have you previously undergone Stem Cell/Exosome therapy?*

Desired Outcomes

What results or outcomes are you hoping to achieve with this treatment?*

Concerns or Questions

Do you have any concerns or questions regarding Stem Cell/Exosome therapy?*

Peptides
Peptides

Medical History

Please answer the following questions to determine your eligibility for peptide therapy.

History of or active cancer (within last 5 years)?*

Pregnant or currently breastfeeding?*

History of severe allergic reactions or anaphylaxis to medications?*

Currently have uncontrolled high blood pressure (>160/100 mmHg)?*

Currently undergoing chemotherapy or radiation treatment?*

Currently diagnosed with untreated autoimmune disease?*

Current active infection or illness?*

History of significant heart disease or recent cardiovascular event (within 6 months)?*

Current or recent (within 5 years) history of cancer/tumors not cleared by your oncologist?*

Primary Goals for Peptide Therapy

Please select all that apply*

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6/7
86 %
General Consent Forms
Please review and agree to the consent statements for each selected treatment.
HIPAA Privacy Authorization Form *

I acknowledge that I have received and reviewed the Notice of Privacy Practices. I authorize the use and disclosure of my health information for the purposes of treatment, payment, and healthcare operations as outlined. I understand that I may revoke this authorization in writing at any time.

General Consent for Treatment *

I voluntarily consent to receive medical care, evaluation, and treatment from this healthcare provider and their team. I understand that my treatment may include physical exams, diagnostic testing, or procedures deemed necessary by the provider.

Telehealth Services Consent Form *

I understand that Telehealth involves the use of audio, video, or other technology to receive care remotely. I acknowledge that I have the right to refuse or stop telehealth at any time and that confidentiality will be maintained as required by HIPAA. Risks include technical failure, unauthorized access, or limited access to emergency care.

Sexual Wellness Consent Form *

I understand that Sexual Wellness treatments may include hormone therapy, sexual enhancement procedures, or counseling to address intimacy and sexual health concerns. I acknowledge that results vary and that potential risks may include hormonal imbalances, allergic reactions, discomfort during treatment, or unsatisfactory results. I agree to inform my provider of any pre-existing conditions or medications.

IV Infusion Therapy Consent Form *

I understand that IV Infusion Therapy involves the administration of fluids, vitamins, minerals, and/or medications directly into the bloodstream. Potential risks include vein irritation, bruising, infection, or allergic reaction. I confirm I have disclosed my medical history and any allergies to the provider.

Peptide Therapy Consent Form *

I understand that Peptide Therapy uses biologically active peptides to promote healing, weight management, or anti-aging effects. I acknowledge that this therapy may have risks including injection site reactions, dizziness, fatigue, or hormonal changes. I have disclosed all relevant health conditions to my provider.

Regenerative Medicine Consent Form *

I understand that Regenerative Medicine may include exosome therapy, PRP, or stem cell-based therapies aimed at repairing damaged tissues. These are often considered investigational and not FDA-approved. Risks may include infection, swelling, pain at injection site, or lack of improvement. I accept these risks and confirm I have provided my fullmedical history.

Hormone Replacement Therapy (HRT) Consent Form *

I understand that HRT involves the administration of hormones to address hormonal imbalances. Risks may include blood clots, breast tenderness, mood changes, or increased risk of certain cancers. I acknowledge that I have discussed these risks with my provider and have disclosed all relevant health history.

Weight Loss Therapy Consent Form *

I understand that Weight Loss Therapy may include medications, dietary guidance, and/or injections. Risks may include nausea, dizziness, low blood sugar, or gastrointestinal discomfort. I acknowledge that outcomes may vary and that I am responsible for following the treatment plan provided.

Additional Weight Loss Consent Items *

Aesthetic Treatments Consent Form *

I understand that Aesthetic Treatments may include cosmetic injections, facials, laser therapy, or other procedures to enhance appearance. Potential risks include bruising, swelling, allergic reaction, scarring, or dissatisfaction with the results. I confirm that I have no known contraindications and have shared my medical history.

Signature

By signing below, I confirm that all information provided is accurate and complete. I understand that this information will be used to determine my eligibility for treatment.

Signature*
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7/7
100%
Summary
Please review your information before submitting.
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