Patient Check-In
Appointment Details (Filled by Provider):
- Promotional Appointment
- Paid Single Appointment
- Use Membership Appointment
- Use Package Appointment
- Consultation Only
- Complementary Appointment
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- Body Cavitation
- Laser Lipolysis
- EMSculpt
- Pressotherapy
- LED Light Therapy
- Deep Cleansing Facial
- Neck Treatment
- Vampire Facial
- Microneedling
- Chemical Peel
- Neurotoxins
- Dermal Fillers
- Filler Dissolvers
- IM Shots
- IV Drip
- Platelet-Rich Plasma / Platelet-Rich Fibrin
- Kybella / Fat Dissolver
- Hair Restoration (Non-injectable)
- Exosome Rejuvenation Therapy
- Fat Dissolver Injections
- Consultation
- Other
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- Abdomen – Upper
- Abdomen – Lower
- Ankles
- Arms – Upper
- Arms – Lower
- Bra Line – Front
- Bra Line – Back
- Back – Upper
- Back – Mid
- Back – Lower
- Bikini Line – Standard
- Bikini – Extended
- Brazilian – Full
- Buttocks – Upper
- Buttocks – Lower
- Calves
- Chest
- Feet / Toes
- Hands
- Hips
- Knees
- Thighs – Inner
- Thighs – Outer
- Thighs – Back
- Thighs – Front
- Underarms / Axilla
- Waist / Sides (Flanks / Love Handles)
- Face – Full
- Face – Lower (Perioral / Jawline)
- Face – Cheeks
- Face – Sideburns
- Upper Lip
- Chin
- Jawline / Beard Area
- Neck – Front
- Neck – Back
- Nape / Hairline
- Full Body
- Other (Specify in Notes)
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- Upper Face – Horizontal Lines
- Upper Face – Between Brows (Frown Lines / “11s”)
- Upper Face – Eyebrow Lift
- Upper Face – Crow’s Feet (Sides of Eyes)
- Upper Face – Bunny Lines (Sides of Nose)
- Mid / Lower Face – Nasolabial Area (Smile Fold Support)
- Mid / Lower Face – Gummy Smile
- Mid / Lower Face – Lip Lines (Smoker Lines)
- Mid / Lower Face – Lip Flip (Upper Lip)
- Mid / Lower Face – Corners of Mouth (Downturned Corners)
- Mid / Lower Face – Chin (Dimples / Orange Peel)
- Mid / Lower Face – Jawline Slimming / Masseter
- Neck & Lower – Neck Bands (Platysmal Bands)
- Neck & Lower – Necklace Lines (Horizontal Neck Lines)
- Neck & Lower – Décolletage (Chest Lines)
- Functional / Other – TMJ / Jaw Tension (Masseter)
- Functional / Other – Migraine / Headache Treatment
- Functional / Other – Excessive Sweating – Underarms
- Functional / Other – Excessive Sweating – Hands
- Functional / Other – Excessive Sweating – Feet
- Functional / Other – Other (Specify in Notes)
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For Patient Use Only:
Kindly review the appointment details above and confirm their accuracy before signing.
I voluntarily request and consent to receive the treatment(s) selected and/or recommended during today’s visit. I confirm that I have provided accurate and complete medical information to the best of my knowledge. I understand that all medical and aesthetic procedures carry potential risks, side effects, and complications, which have been explained to me or made available for review.
I acknowledge that results are not guaranteed and may vary between individuals. I authorize the provider and clinical staff to perform the requested treatment and any medically appropriate modifications necessary in their professional judgment.
By signing below, I confirm that I understand the above and give my informed consent to proceed.
For Provider Use Only:
- Jasmin
- Belinda
- Eden
- Alan
- Gia
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