N A M E A E S T H E T I C S W E L L N E S S A D D R E S S H O M E E M A I L A D D R E S S M O B I L E W O R K B I R T H D AT E C I T Y S TAT E Z I P F I R S T M I D D L E L A S T D AT E I would like to see results in the following areas of concern within my Chapter journey: How did you learn about Chapter? Fine Lines/Wrinkles Thin Lips Brown/Age Spots/Sun Damage Freckles Blotchy Skin Acne Acne Scarring Texture Pigment Facial Veins Fullness Under Chin (Double-Chin) Facial Redness Brow Shaping Improving Libido/Sexual Function Treating Urinary Incontinence Night Sweats/Hot Flashes Length/Fullness of Lashes Dry Skin Oily Skin Clogged/Large Pores Rough Texture Melasma/Mask of Pregnancy Anti-Aging Sagging Skin Loss of Elasticity Psoriasis TV Ad Other Direct Mail Google Instagram Facebook Referral Snapchat Radio Chapter’s Website 'ifficulty 6leepinJ 0ood 6ZinJs +ormonal ,mEalance /ack of (nerJy)atiJue )oJJy 7hinkinJ %ody 6culptinJ)at 5eduction Cellulite :eiJht /oss 6tretch 0arks +air 5emoYal ,naEility to /ose :eiJht %oost ,mmunity 2ptimi]e $thletic Performance +air /oss+air 7hinninJ P L E A S E C H E C K A L L T H AT A P P LY ( C O N T I N U E S O N N E X T PA G E ) P L E A S E P R O V I D E T H E I R N A M E S O W E C A N T H A N K T H E M ! Appointment Confirmations and Special Promotions Sharing is caring. Cancellation policy Chapter has a unique appointment confirmation and online customer communication system. Please check one or more of your preferred methods of contact: Pictures will be obtained for medical records. If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed. May we use your before & after photos? • All service reservations require a credit card for guarantee. • In efforts to provide a spectacular patient experience for both you and our patients, we require a minimum 24 hours advance notice of appointment cancellations or chanJes. $ppointments cancelled or chanJed after the notification period Zill result in a cancellation fee: a charge of 50% of the treatment fee for that day Botox fee will be a minimum of 20 units. • Late arrivals will result in the appointment concluding at the original time scheduled and at the regular treatment price. 1o notification of cancellation Zill result in a full charge of the regular treatment price. Please check one or more of your preferred methods of contact for special offers and promotions : Email Yes Email SMS/Text Message No SMS/Text Message Please do not contact me for appointment confirmations Please do not contact me for appointment confirmations I N I T I A L H E R E S I G N AT U R E D AT E Skin/Health Assessment N A M E Do you have any allergies? Please list allergy and your reaction: Do you have any medical conditions? Please list: Are you taking any medications, vitamins and/or supplements? Please list: Have you ever had any surgeries? Please list: Have you ever had any type of cancer? If yes, please explain when diagnosed and what kind: Are you currently being treated for cancer? If yes, please explain the type of treatment you are receiving: Do you have, or have you had, unusual skin lesions? If yes, please explain: When you have a cut, scratch or sore, does your skin color have a tendency to hyper- or hypo- pigment? Do you have a history of Keloid scarring (white, raised, hardened scars)? Do you have a history of skin disorders such as: eczema, psoriasis, rashes? Do you bruise easily or heal slowly? Are you a smoker? Do you have a pacemaker? Are you under the care of a dermatologist or physician? Please explain: Are you pregnant? Do you have a history of cold sores? Have you used Accutane in the past 6 months? Do you use tanning beds? Do you use sunscreen? How often?: Attempting pregnancy? Breastfeeding? Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N N N N N N N N N N N N D AT E S I G N AT U R E T H E N O N - C L I E N T C O N D I T I O N S P E C I F I C P R O T O C O L I S A U T H O R I Z E D : Authorized, NO exceptions Authorized, WITH exceptions: D AT E D AT E R N M E D I C A L D I R E C T O R C L I N I C S TA F F C O M P L E T E