416.996.6806 hello@aestheticsbyshani.com

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Intake Form

If you are looking to book an appointment, the best way would be to call, text or email me. If we have already spoken, you are encouraged to fill out the form below so that we may make the most of our time together. This helps me make sure I have all the information I need when we meet.

The information you enter below will be the start of your care plan and will be kept confidential.

About You
Name:*
First Last
Address*
Street Address Address Line 2 City Postal Code
Cellphone:*
Business Phone:
Email:*
Date of Birth*
Month
Day
Year
Name of your Physician:*
First Last
Do I need to be discreet with messages?*
- Yes
- No
Appointment Preference
Do you have a preferred time for appointments?*
- Morning
- Afternoon
- I don't have a preference
What is the best way to contact you?*
- Cellphone
- Business Phone
- Email
- I don't have a preference
Medical Background
Are you or could you be pregnant or nursing?*
- Yes
- No
Do you experience easy bruising/bleeding or excessive bleeding requiring special treatment?*
- Yes
- No
Have you ever had any reaction to any type of anesthetic - dental surgery?*
- Yes
- No
Do you or any family members suffer from the following neurological disorders?
Myastenia Gravis*
- Yes
- No
Eaton Lambert Syndrome*
- Yes
- No
Do you have Bioaclamide, Dermalive, Dermadeep, Beauticall, Artecoll, Artesense or any semi permanent/permanent filler in your face?*
- Yes
- No
Please check if you have or have had any issues with the following:*
- Eczema Acne
- Laser Therapy
- Keloid Formation
- Chemical Peels
- Herpes/Cold Sores
- Dermabrasion
Check any of the following which you presently have or have had:*
- Cancer
- Diabetes
- Angina
- Emphysema
- Tuberculosis
- Asthma
- Thyroid Disease
- Migraines/HA
- Seizures/Epilepsy
- Stroke
- Lupus
- High Blood Pressure
- Heart Murmur
- Rheumatic Fever
- Mitral Valve Prolapse
- Congenital Heart Defect
- Cardiac Pacemaker
- Artificial Valve, Joint, Prosthesis
- Hirsutism
- Anemia
- Sickle Cell Disease
- Blood Transfusions
- Liver Disease
- Jaundice
- Stomach Ulcer
- Kidney Disease
- Arthritis
- Sinus Trouble
- Psyciatric Treatment
- Addictions/Alcoholism
- Hepatitis
- Glaucoma
- HIV/AIDS
- Herpes/Cold Sores
- Recent Dental Procedures
- Warts
- Skin Conditions
- Skin senitivities (to the sun/other)
- Metal Implants (IUD)
- Pacemaker
- Blood Disorders (Bleeding/Clotting)
- Oral Corticosteroids
- Faintng Spells
- Aspirin/Blood Thinners
- Keloids (Excessive Scarring)
Have you ever been treated in the past with:
Botox*
- Yes
- No
Have you ever experience any problems with the procedures?
HA Fillers*
- Yes
- No
Have you ever experience any problems with the procedures?
Do you have or have you had any other diseases or medical problems not listed on this form?*
- Yes
- No
Please describe the diseases or medical problems here:
Do you have any allergies to medications or other substances?*
- Yes
- No
Please describe the allergies here:
Please list medications currently being taken, in particular: any non steroidal anti-inflammatories (Advil, Motrin, ASA), or Anticoagulants/Plavix:*
If None, type "NA"
Please list any non-prescription medications/vitamins being taken, in particular Vitamin E, Gingko*
If None, type "NA"
Do you smoke?*
- Yes
- No
Amount per week?
Do you drink alcohol?*
- Yes
- No
Amount per week?
I hereby state that the above medical history is, to the best of my knowledge, accurate and complete. If I ever have any change in my health, or medications change, I will inform the primary health care practitioner at the next appointment without fail. If deemed advisable, I grant permission for my physican to be contact for details and advice.*
- Yes

Services

Botox®

Fillers (Juvéderm®)

Micro-Needling

Mesotherapy

Love Your Skin

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Get In Touch

West Oaks Trails

416.996.6806

hello@aestheticsbyshani.com

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