Six62 Aesthetics & Wellness

General Client Intake Form

Please complete all applicable sections. This form helps us review safety, treatment options, and care planning.

Client Information

Client Name *

Date of birth *

Phone *

Email *

Street Address *

City *

State *

Country *

Postal Code *

Emergency contact *

Emergency contact phone *

Primary care provider *

How did you hear about us? *

Preferred contact method *

Phone

Text

Preferred pharmacy, if applicable *

Visit Information

Reason for visit or treatment interest *

Services you may be interested in *

Aesthetic treatment

Facial or skin treatment

Laser hair removal

Body contouring

Massage or stretch therapy

Weight management

Wellness injection or IV hydration

Medical cannabis certification

Other

For office use only

Medical History

Check all that apply. Add details where needed.

Medical Conditions *

No known medical conditions

Diabetes

Stroke or blood clots

Autoimmune disease

Kidney disease

Thyroid disease

Asthma or COPD

Anxiety, depression, PTSD, or mood disorder

Keloid or abnormal scarring

Fainting or dizziness with procedures

High blood pressure

Heart disease or chest pain

Bleeding or clotting disorder

Cancer history

Liver disease

Seizures or epilepsy

HIV, hepatitis, or immune disorder

Migraines

Cold sores or herpes simplex

Pregnant, trying to conceive, or breastfeeding

Other medical conditions or details *

Allergies and Reactions *

No known drug allergies

Latex

Lidocaine or numbing medication

Adhesive

Iodine or contrast

Food allergy

List allergies and reactions *

Current Concerns

Current symptoms, recent illness, infections, fever, rash, skin changes, or recent dental work *

Medications, Surgeries, and Social History

Current Medications and Supplements

List prescription medications, over-the-counter medications, vitamins, injections, and supplements *

Select *

Blood thinner or aspirin

Steroid use in last 30 days

Antibiotic use in last 30 days

Isotretinoin or Accutane use

Immunosuppressant medication

Weight loss medication

Medication notes *

Smoking, Nicotine, Alcohol, and Substance History *

Never smoker

Current tobacco use

Former tobacco use

Current vaping

Nicotine use

Cannabis use

Alcohol use

Details: frequency, amount, quit date, or concerns *

Acknowledgments and Signature

Safety Questions *

Additional safety notes *

Client Acknowledgment *

I confirm that the information I provided is accurate and complete to the best of my knowledge

I agree to update Six62 Aesthetics & Wellness if my medical history, medications, allergies, pregnancy status, or health status changes.

I understand this intake form does not replace a consultation, medical assessment, or service-specific consent form.

I understand that services may be delayed, modified, or declined if the provider determines treatment is not appropriate or safe.

I understand that individual results vary and no outcome is guaranteed.

I authorize Six62 Aesthetics & Wellness to contact me using the contact information I provided regarding appointments, care, and account matters

Questions or concerns you want to discuss before treatment *

Client signature *

Clear

Date *

Parent or guardian signature, if applicable *

Clear

Date *

Provider review *

Provider signature *

Clear

Date *

Indemnification Clause *

I understand and agree that Six62 Aesthetics & Wellness, its owners, providers, employees, contractors, representatives, and affiliates shall not be held liable for any claims, losses, damages, complications, injuries, expenses, or legal fees that may arise from my treatment, services received, failure to follow pre-care or aftercare instructions, omission or misrepresentation of my medical history, medications, allergies, prior procedures, health conditions, or any other information necessary for safe treatment. I agree to indemnify, defend, and hold harmless Six62 Aesthetics & Wellness from and against any and all claims, demands, actions, liabilities, costs, or expenses resulting from my participation in services, except in cases of proven gross negligence or willful misconduct by Six62 Aesthetics & Wellness.

I understand that Six62 Aesthetics & Wellness respects my privacy and is committed to protecting my personal, medical, and treatment-related information. I acknowledge that my information may be collected, stored, and used for purposes including scheduling, treatment planning, medical documentation, billing, communication, follow-up care, and business operations related to services provided. I understand that Six62 Aesthetics & Wellness will not sell or intentionally disclose my personal or medical information to unauthorized third parties, except as required by law, for payment processing, treatment coordination, insurance or financing purposes when applicable, or with my written consent. I also understand that communication by phone, text message, email, or online booking systems may carry some risk, and I consent to being contacted regarding appointments, treatment follow-up, account matters, and service-related updates.

Photo Consent *

I understand that photographs and/or video images may be taken before, during, or after my treatment for the purpose of documenting my care in my private medical chart only. These images may be used by Six62 Aesthetics & Wellness and my treating provider to evaluate treatment progress, support clinical documentation, compare before and after treatment changes, and maintain an accurate record of services provided. I understand that these images will not be used for marketing, social media, email campaigns, website content, digital advertisements, printed promotions, training, or public display unless I complete and sign a separate written marketing/photo release. I understand that I may accept or decline medical chart photography, and declining photo documentation may limit the provider's ability to visually track treatment progress. I have had the opportunity to ask questions and understand the purpose of this consent.

Select One *

I ACCEPT. I consent to photos and/or video images being taken and stored in my private medical chart for clinical documentation only.

I DECLINE. I do not consent to photos and/or video images being taken for my medical chart at this visit.