New Patient Intake Form

New Patient Intake Form

Name
MM slash DD slash YYYY
What are your areas of concern? (check all that apply)
Are you interested in learning more about the following? (check all that apply)
Have you had the Covid vaccine?
Are you pregnant or planning to become pregnant?
Breastfeeding?
Do you have any neuromuscular disorders
Do you have a history of cold sores/fever blisters around the mouth and lips?
Please list if Yes
By signing my name I give consent for evaluation and treatment by Michele Lane and staff. I give consent for pictures to be taken for the medical chart. I understand the pictures taken will not be shared without my consent. I also understand no treatment will given if I refuse to take pictures. By signing electronically using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this Agreement (hereafter referred to as your 'E-Signature') is as valid as if you signed this Agreement in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Michele Lane. You are also confirming that you are authorized to enter into this Agreement in your behalf. You understand that a paper copy of this Agreement can also be obtained by contacting Michele Lane at L3Aestheticsinfo@gmail.com or by calling (405) 570-3418.