Surgical Intake FormPlease fill out the following form prior to your appointment.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 specifyMedical Conditions/Illness/Past Surgeries?YesNoPlease specifyDo 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 6 months?YesNoAre you interested in monthly payments?YesNoWould you like to hear about any of our other services? (Please check all that you are interested in)Laser Skin TreatmentsInjections (Botox and/or fillers)Medical Grade Skincare ProductsHow 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 SpecialsSign 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.
