Live example - nothing you submit is saved.Back to the template

Medical Spa Intake

Please complete before your first appointment. It takes about eight minutes.

Full name* (required)Date of birth* (required)Email address* (required)Phone number* (required)Address* (required)Emergency contact - name and number* (required)Doctor's name and practice* (required)

Medical history

Have you ever been diagnosed with any of these?* (required)

Heart condition High blood pressure Stroke Diabetes Epilepsy Autoimmune condition Bleeding or clotting disorder Thyroid condition Kidney or liver disease Cancer Hepatitis or HIV Mental health condition None of these

Details, including when diagnosedPrevious surgery and datesAre you pregnant or breastfeeding?* (required)

Medication and allergies

All medication* (required)Supplements and herbal remediesAllergies and reactions* (required)Are you taking anything that thins the blood?* (required)

Skin history

Skin type* (required)

Any of these?* (required)

Acne Rosacea Eczema Psoriasis Melasma Cold sores Keloid scarring Vitiligo None of these

Are you using any of these?* (required)

Prescription retinoid Retinol AHA or BHA acids Hydroquinone Benzoyl peroxide None of these

Recent sun exposure or sunbed use?* (required)Isotretinoin in the last 12 months?* (required)

Lifestyle and consent

Do you smoke or vape?* (required)Alcohol* (required)

I consent to a clinical assessment and consultation* (required)

I understand any prescription treatment requires assessment by a prescriber* (required)

The information above is accurate and complete, and I'll tell you if it changes* (required)

Leave this field empty