Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Gender Identification
Pronouns
If you feel comfortable, please check your pronouns below.
If your pronouns are not listed above, and you are comfortable in sharing, please list your pronouns in the space provided below.
Date Of Birth
*
MM
DD
YYYY
Occupation
Health Card Number
*
Family Physician
*
Emergency Contact
Please list the name, relationship, and phone number, including the area code, of who we should contact in case of an emergency.
Medical Conditions
*
Please check all that apply.
If you answered yes to Cancer, please explain further in the space provided below.
If you answered yes to Cancer, please explain further in the space provided below
Current Or Past Illnesses
Please provide any current or past illnesses that are not listed above.
Are You Pregnant or Breastfeeding?
*
Are You Taking Hormones or Birth control Pills?
*
Past Surgeries
Please list any surgeries you have had.
Notes:
Please list any other information that you feel would be helpful leading up to your appointment.
Let Us Know
*
How did you hear about our clinic?
If you selected, Other please specify.
I am Interested In
*
Please check all that apply.
If you selected, Other please specify.
Studio Skin Can Help:
What area/s are you interested in treating, or have more questions about? Please check all that apply.
If you selected, Other please specify.
May we contact you to remind you about upcoming or missed appointments?
*
Please select one.
May we contact you regarding new services, products and procedures?
*
Please select one.
Preferred Method Of Contact
If you selected Yes to either of the above 2 questions, how would you like to be contacted?
Please provide the information of your preferred method of contact.
