Injectable Assessment Form Please fill out the following form for your assessment.First Name *Last Name *GenderPreferred PronounsOccupationCanadian Citizen/Permanent Resident?YesNoMB Health (6 digit #)0 / 6PHIN (9 digit #)0 / 9OtherStreet AddressCityState/ProvinceZIP / Postal CodeD.O.B.DayMonthYearPhoneWorkHomeCellMedications (including Vitamins and Supplements)?YesNoPlease specify wich medicationsList all Allergies/Reactions?YesNoPlease specifyAre you allergic to wasp stings?YesNoUnsureIf Yes describe reaction:Medical Conditions/Illness/Past Surgeries?YesNoIf Yes please specify:Do you smoke tobacco?YesNoHow much per day?Do you consume or smoke marijuana?YesNoHow often?Do you have history of Cold Sores?YesNoHow often?Are you pregnant?YesNoBreastfeeding?YesNoDo you plan on becoming pregnant within the next 4 months?YesNoHave you had Filler/Hyaluronic Acid Injections?YesNoIf Yes please specify:Have you had Botox® Injections?YesNoIf Yes, last treatment date:Do you have history of Cold Sores?YesNoDo you use tanning beds/booths/self-tanner?YesNoAre you currently using Retin-A®/Retinol/Tazorac®?YesNoIf Yes please specify What strength? For how long? How frequently?Have you ever used any products that caused a bad reaction?YesNoIf Yes please describe reaction:How did you hear about our clinic?Magazine AdTikTokFacebookInstagramFriends/FamilyWebsiteGoogleReal Self / Rate MDOtherSpecifyThe above information is accurate to the best of my knowledge.DateDayMonthYearSignatureSend MessagePlease do not fill in this field. Get Access to Our Exclusive Monthly Specials Sign Up TodayFirst Glance Rewards® Join the First Glance Rewards Program®Collect points every time you visit. As a member, you’ll save on your favourite treatments. SubmitPlease do not fill in this field.
