Intake Form

Please fill out the following form.

First name(Required)

Last name(Required)

Email(Required)

Date of birth(Required)

Gender(Required)

Male

Female

Rather not say

Address(Required)

Phone(Required)

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Have you had any of these cosmetic treatments in the past?(Required)

Neuromodulators (AKA Botox)

Dermal Fillers

Mesotherapy

Weight loss injections

Vitamin injections

None of the Above

Allergies (Medications, food, etc)(Required)

Current Medications (include OTC and supplements)(Required)

Please check any conditions that apply to you:

Lou Gehrig's disease

Myasthenia gravis

Bell's Palsy

Double vision

Multiple sclerosis

Parkinson's disease

History of Herpes around the lips

Autoimmune Disease

NO CONDITIONS

Other condition/s

WOMEN (non menopausal)

Are you currently breastfeeding?(Required)

Yes

No

Any chance of pregnancy?(Required)

Yes

No

I attest that the information I have provided is true and accurate to the best of my knowledge.

Your Signature(Required)

Print Name(Required)

Select a date

Contact

Tel: 254-856-9126

Fax: 254-230-0013

Email: service@pfmweightloss.com

Location

Policies

Currently Telemedicine

Our policy