CLIENT INTAKE & MEDICAL HISTORY FORM

Please complete this form in advance to ensure a smoother visit to StellarCell Aesthetics Center. A paper version is also available at the Center.

Confidential – Personal Health Information (PHI)

This form contains personal health information and shall be handled with strict confidentiality. All information shall be collected, used, disclosed, retained, and protected in compliance with applicable Ontario privacy laws, including the Personal Health Information Protection Act, 2004 (PHIPA), and in accordance with the clinic’s privacy, security, and records management policies.

CLIENT INTAKE & MEDICAL HISTORY FORM
What are your primary skin goals? (Check all that apply)
Areas of concern: (Check all that apply)
Relevant Medical Conditions? (Check all that apply)
Any recent or incoming hospitalization/operation?
Are you currently taking any prescription medication?
Are you currently taking any over-the-counter vitamin, supplement, or herbal medication?
Any allergies or sensitivities to medications, food, insects, animals, latex, supplements, herbal remedies?
Have you ever had an anaphylactic reaction?
Are you pregnant, trying to get pregnant, or lactating (nursing)?
Any previous cosmetic procedures? (Check all that apply)
Any complication with previous cosmetic Procedures?
Products currently used: (Check all that apply)
Active ingredients used: (Check all that apply)
Do you see a dermatologist or aesthetician regularly?
Relevant Medical Conditions? (Check all that apply)
How did you hear about us? (Check all that apply)
I consent to receive:
Affirmation