Virtual Care Form – Aesthetic Care

Name *

First

Last

Email *

Email

Confirm Email

Where did you hear about us or who referred you? *

Preferred Appointment Day(s) *

Preferred Appointment Time *

Age

Date of Birth//

Gender

Phone Number *

Occupation

Family Doctor

Pharmacy Name

Pharmacy Fax Number

Is this a First Visit or a Follow-Up Visit? *

Do you have any medical problems?

Please list any medications you are currently on

Please list any allergies you may have

What are you hoping to achieve? *

What are you aesthetic concerns?

I Understand that this method of communication is not secure in the same way as a private appointment in an exam room. *