* INDICATES REQUIRED FIELD

Contact & General Information

* First and Last Name

Date of Birth
--Month-- 010203040506070809101112 --Date-- 01020304050607080910111213141516171819202122232425262728293031 --Year-- 19301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015

Home Phone Work Phone Mobile Phone
      

* Email Address

Street Address

City State ZIP Code
      

May we contact you?
Yes    No

If yes, preferred contact methods?
Home Phone  Work Phone  Mobile Phone  E-mail  Mail

To better suit your needs, when is the best day and time for an appointment?

Emergency Contact

In case of emergency, please contact:

Name:

Phone Number:

Relationship:

Alternate Phone Number:

How did you hear about us?

Internet:

• American Health & Beauty^™
• GETPROLO.com

Have you visited our website?

Yes    No

Health History

Are you currently under the care of a physician?
Yes    No

If yes, for what conditions are you being treated?

Do you currently have any significant illnesses or have you had any significant illnesses in the past?
Yes    No

If yes, please list:

Have you ever had surgery?
Yes    No

If yes, please list:

Have you ever had any cosmetic procedures?
Yes    No

If yes, please list:

Do you take any medications regularly?
Yes    No

If yes, please list. (Please also list over-the-counter medications):

Do you have any allergies or do you react to any medications?
Yes    No

If yes, please list:

Do you currently have, or have you had in the past, illnesses of:

Photography Release

I authorize Bair Medical Spa to take photographs of me and use them as an aid in my treatment. I understand that these photographs will help document the progress of my treatment. I hereby authorize and consent to the above-described photography. These photographs will be completely confidential unless checked below.

I hereby authorize and consent to the above-described photography being used by Bair Medical Spa for study reporting or promotional purposes and that any photographs taken will remain the property of Bair Medical Spa. If used for any of these purposes, I understand that my identity will be kept strictly confidential— no names will be released.