New Client Form - Kia Ora Aesthetics

Patient Intake Form

First Name

Last Name

Date of Birth

Age

Occupation

Prefered Name / Nickname

Patient Gender

Phone no.

Alternate phone number

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Number

Relationship to the patient

How did you hear about us?

If other, please specify

Occupation

Disability ?

Yes

Details of disability

If other, please specify

If other, please soecify

Do you have any allergies or any chronic conditions not listed above?

If yes, please specify

If other, please specify

Are you allergic to any medications?

Yes

If yes, please specify

What is your current skin care routine?

Are you wearing contact lenses?

Yes

Are you pregnant/breastfeeding/nursing?

Yes

Not applicable

Are you wearing any implantable medical devices? If yes, what are these devices?

Are you currently taking any medications? If yes, please list them below:

Were you previously hospitalized? If yes, please indicate when and why:

Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:

How do you manage stress? Please elaborate:

Have you done laser hair removal before?

If yes, please specify last date of treatment and areas treated

Who is your primary care doctor:

Where is your primary care doctor located ?

Phone Number of primary care doctor:

Do you smoke?

Yes

How many years did you smoke?

If you quit, when did you stop?

Do you drink alcohol?

By checking this box, I hereby indemnify and hold harmless Kia Ora Aesthetics (Pty) Ltd, the Spa and/or the Property Owner, Staff and Management from any injury, disease, death, damage or loss I may experience.

I declare that I will participate in all activities and/or treatments at the facilities and externally at my own risk.

I understand that the services received are not a substitute for medical care and any information and/or advice given by the aesthetician/ beauty therapist is for educational purposes only.

All the information supplied on this form is correct and I agree that I cannot hold the aesthetician/ beauty therapist responsible for any loss, damage and/or injury or illness howsoever caused.

I have read and understand the patient information provided.

I have had my procedure adequately explained to me by the therapist.

I have received all of the information I desire concerning my procedure and I understand all pre- and post-treatment recommendation and agree to adhere to them.

I freely assume any risks of complications or injury from known or unknown causes associated with related to or otherwise arising out of this procedure.

I have the right to consent to or refuse a procedure at any time prior to its performance.

I must notify the therapist if my medical history changes throughout the entire treatment.

I will inform the clinic within the first 3 weeks if I am not satisfied so that the problem can be addressed immediately.

I understand that a slot for my treatment has been reserved specifically for me. Should I not be able to attend the treatment at that specific time, I am obligated to provide 24 hour notice. If not, I understand that the session will be charged to me at the full price.

I have read and agree to the Terms & Conditions, Lash Lift Information, Laser information, Medical Aesthetics Care, Post Facial Care/ Waxing Instructions, Privacy Policy, and the Bookings Policy.

I consent to have this website store my submitted information so they can respond to my inquiry

I have read and agree to the above information and I consent to and authorise Kia Ora Aesthetics to perform any treatment on me.

Date