Intake Form

Elite Medical Aesthetics

Intake Form

Dear Valued Patient,

Thank you for choosing Elite Medical Aesthetics! Please take a moment and fill out our intake form prior to your appointment.

If you have filled out this form over the last 6 months then you do not need to fill it out again.
The information will be transmitted through secure path (encrypted).


COVID Precautions

If you checked any of above then please contact us prior to your appointment. We will be able to advise and if necessary to re-schedule your appointment.

Cosmetic Questionnaires::

Medical Information

Explain your prior medical and any surgery you have had.
List your allergy to medications, food ....
Please make sure you list all medication as well as any of herbs, supplements you take ( fish oil, vitamins, over the counter medications) and aspiring, ibuprofen, advil,...

Your Address:

Please type your full name as representation of your signature for submitting the information and accepting our HIPAA Policy to protect your data. You may review our HIPAA privacy policy as linked on the page.