New Patient Form

Please list any other medical conditions you have that are not listed above.

Have you ever had Dysport®/BOTOX®/fillers? Please list other skin treatments you have had previously.

Do you have permanent cosmetics?

Do you have an existing skin condition even in the area not being treated?

Have you ever been treated by an endocrinologist?

If you have had any surgeries, please list them here.

Have you ever had a reaction to any drug? If so, please list here.

Who is your primary care physician?

Are you pregnant?

Yes No

Lifestyle

Please give approximate amounts per day.

What are your conerns today?

Are there specific treatments that you would like to hear more about today?

How did you hear about us?

Emergency Contact Phone Number

Acceptance

I affirm that all medical and additional information is true and correct to the best of my knowledge. I consent to have Trinity Aesthetics & Laser provide treatment and understand that no guarantee is given as to the specific results I may achieve. I will immediately advise my medical provider of any changes in my medical condition.

Trinity Aesthetics & Laser

Dr. Janie Simmons

88 Village Lane, #150

Colleyville, TX 76034

MSPA_______

CC_______

Lifestyle

Hours of Operation

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