intake

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intakeOro Medspa2023-02-22T11:28:52-05:00

Medical Intake Form

Client Information / Medical History

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Best number to reach you *

Email address *

Emergency Contact Person *

Emergency Contact Phone Number *

Preferred method of payment

myCherry
CareCredit Financing
Major Credit Card
Cash

Please indicate the services and areas of interest *

RF Microneedling
truSculpt iD Fat Reduction
Fuller Lips
Wrinkles and Fine Lines

Do you have or have you ever had any of the following conditions *

Lymphedema
Seizures and /or Epilepsy
Diabetes
Past Smoker
Current Smoker
Cancer and/or precancerous lesions
Heart Condition
High Blood Pressure
Blood clots/Bleeding Disorders
Herpes Virus/Cold Sores
Pregnant or Actively trying to get pregnant
None of the above

If other not listed, please explain as well as list of medications currently taking

Are you allergic to any medication(s) (if no type NO) *

Have you ever had Fillers and/or Injectables (Botox, etc) if No, type No, if yes, please explain when was the last time *

Acknowledgement *

By clicking here and signing this form, I certify that I have answered all the questions truthfully.

Date / Time *

Signature *

245 Old Hook Road, Westwood, NJ 07675

Phone: (201) 754-1091

Oro (Gold) symbolizes the purity of the spiritual aspect of “All That Is”. It is symbolic of spirituality and development in the realm of complete understanding, allowing one to both attain and maintain communion with the source of all beings.

©2023 Oro Medspa™ is a Registered Trademark of Oro Medspa Group LLC. 245 Old Hook Road, Westwood, NJ 07675. (201) 754-1091
Medical Director Dr. Suhel Ahmed.

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