PERSONAL INFORMATION Today’s Date: ______________

Last Name: ______________________________________ First Name: ___________________________

ADDRESS: ____________________________________________________________________________
_____________________________________________________________________________________
DOB: _______________ Home Phone: _______________ Cell Phone: ________________
Age: _____ Gender: Male / Female Email address: _________________________________
Occupation: _______________________ How did you hear about us: ____________________________
EMERGENCY CONTACT: Name: _________________________ Relationship to you: _________________
Phone Number: __________________________ 2 nd Phone Number: ____________________________
I AM INTERESTED IN:

 Botox  Stretch Marks Reduction

 Dermal Fillers  Microneedling
 Chemical Peels  Laser Hair Removal
 Body Contouring  Vaginal Rejuvenation
 Face Contouring  Hormone Therapy
 Weight Loss  Wrinkle Reduction
 Skin Care  Sun Spots/Brown Spots/
 Acne/Scar Removal Hyperpigmentation Removal
 Facial Skin Tightening  Other:
 Body Skin Tightening ______________________________

MEDICAL HISTORY
Are you currently under the care of a physician/dermatologist? YES / NO
If yes, for what:________________________________________________________________________
What medications/supplements do you currently take? _______________________________________
_____________________________________________________________________________________
Are you pregnant/breastfeeding? __________
Tobacco Use YES / NO Amount:_______________
Alcohol Use YES / NO Amount:_______________
Coffee/Tea/Soda/Caffeine YES / NO Amount:_______________
Daily Exercise YES / NO Amount:_______________
Accutane/Retinol YES / NO Amount:_______________
Please list any ALLERGIES including Latex, Medications, Food, and/or other substances:
_____________________________________________________________________________________
_____________________________________________________________________________________

Please circle any of the following that pertain to you, past or present:
Abnormal Bleeding Anxiety/Depression High Blood Pressure Diabetes
Autoimmune Disease Mood Swings Migraines Seizures
Flip Page Over 
 Sleep Apnea Thyroid Disease Blood Clots Anemia
Eczema/Psoriasis Cold Sores GI Issues Stroke
HIV/AIDS Hepatitis Acid Reflux/Heartburn Cancer
Cardiac Disease COPD/Asthma Other: ___________________

Any recent sun exposure/tanning beds/self-tanning lotions that have changed the color of your skin?
If yes, explain. _________________________________________________________________________

Do you have thick or raised scars? _________________________________________________________

Do you have Hyper Pigmentation (darkening of the skin) or Hypo Pigmentation (lightening of the skin) or
marks after physical trauma? _____________________________________________________________

I understand that Dr. Junith Thompson, AFFORDABLE BEAUTY, and staff are performing services for me that are
related specifically and only to cosmetic improvement of my appearance which may include the use of aesthetic
equipment, technology, and products to deliver the following treatments as needed for my goals. I understand
that medical and aesthetic practices are not an exact science, so no results have been guaranteed to me. I have
been made aware that results vary from person to person. _____Initials

I have been informed that firmness, hardness, nodules, redness, tenderness, bruising, swelling, and pain are
common side effects for some or all of the treatments I will receive here at AFFORDABLE BEAUTY. Less common
side effects that can occur are itching, dimpling, hyperpigmentation/hypopigmentation, asymmetry, necrosis,
numbness, blisters, or burns. Rare occurrences of fainting or dizziness have been noted during and/or after
treatment. _____Initials

I do consent to photographs, digital images, and before and after results to be taken and used to evaluate
treatment effectiveness, for medical education, training, professional publications, and/or sales or marketing
purposes. I understand that my identity will not be revealed without my written and signed consent. _____Initials

Before and after treatment instructions have been discussed with me. The procedure, potential benefits and risks,
and alternative treatment options have been explained to my satisfaction. _____Initials

I have provided my information to the best of my knowledge. I have read and understand all information
presented to me before consenting to treatment. I have had all my questions/concerns answered and addressed.
_____Initials

Patient Signature: _______________________________________________ Date: __________________

Witness Signature: ______________________________________________ Date: __________________