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MadePetal Clinic and Spa - Medical Intake Form

MadePetal

CLINIC AND SPA

CONFIDENTIAL CLIENT MEDICAL & PROCEDURE INTAKE FORM

Client Information

Full Name

Date

Address

City

State

Phone Number

Email Address

Date of Birth (DOB)

List of Intended Procedures

Please indicate the treatment(s) or procedure(s) you wish to undergo

Medical Background Checklist

Please check all that apply

Are you pregnant or nursing?

Do you have any kind of tumor or cancer?

Do you have a wound that has not healed?

Do you have any plastic, bone cement, or metal implants?

Have you had surgery in the last 6 months?

Do you have thrombosis or thrombophlebitis?

Do you have any current infection or infectious disease?

Do you have untreated diabetes or high cholesterol?

Are you epileptic?

Do you have any cardiac or vascular disease or condition?

Do you have a history of internal bleeding?

Do you have abnormally high or low blood pressure?

Have you undergone a transplant?

Do you have any keloid scars?

Do you have a neurological or immune disorder?

Do you have any condition affecting the heart, kidneys, or liver?

Please note: If you answer "Yes" to any of the above, you may not be eligible for treatment. Consult with your therapist or physician.

MEDICATION AND HEALTH DETAILS

Are you currently taking any medications?

Are you allergic to any foods or medications?

Are you taking any vitamins or supplements?

Are you currently under a physician's care?

Are you taking any recreational drugs?

Emergency Contact Information

Name

Relationship

Phone Number

Confidentiality Notice: All information provided will be kept strictly confidential and used solely for your safety and treatment planning.

madepetaling@gmail.com

08130586133

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MadePetal Clinic & Spa

Your oasis of relaxation and rejuvenation.

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Contact Info

Same Building with Trust Micro-Finance Bank, Opposite The Palms, Km1, Magboro, Lagos-Ibadan Express Way

08130586133

madepetalng@gmail.com

Business Hours

Monday - Friday: 8:00 AM - 6:00 PM

Saturday: 8:00 AM - 5:00 PM

Sunday: Closed