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Client Intake Form

Please complete our new client intake form prior to your appointment. To download and print a PDF, click here.

General Information

Name(Required)

First Last

Birthday(Required)

MM slash DD slash YYYY

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Sex(Required)

Male

Female

Occupation

Emergency Contact Name

First Last

Emergency Contact Phone #

Would you like to be added to our email list for specials and discounts?

Yes

No

How Did You Hear About Us?

Medical History

Do you have any chronic medical conditions that we should know about?(Required)

Yes

No

Please List:

Are you currently taking any medications?(Required)

Yes

No

Please Explain:

Do you have any allergies?(Required)

Yes

No

Please Explain:

Do you have type 1 or type 2 diabetes?(Required)

Yes

No

Do you have any known kidney or liver disorders?(Required)

Yes

No

Do you have photosensitivity to sun exposure?(Required)

Yes

No

Do you currently have cancer?(Required)

Yes

No

Have you had cancer in the past 12 months?(Required)

Yes

No

Do you have any thyroid problems?(Required)

Yes

No

Do you have high blood pressure?(Required)

Yes

No

Do you any cardiovascular conditions?(Required)

Yes

No

Do you have any medical devices implanted including, but not limited to, hearing aids, a pacemaker, or hormonal pellets?(Required)

Yes

No

Please List:

What concerns would you like addressed today?

Do you want to lose body fat?(Required)

Yes

No

From What Area?

Do you want to tighten skin on your body?(Required)

Yes

No

From What Area?

Do you want to reduce cellulite?(Required)

Yes

No

From What Area?

Please list you regular exercise habits:

Please describe your current dietary habits:

How many ounces of water do you drink daily?

Δ

CC Solutions MEDSPA

Address:

5801 Long Prairie Rd #600 Suite 26
Flower Mound, TX 75028

Phone:

817-727-2979

Email:

ccsolutionsbsnl@gmail.com

MedSpa Hours:

Monday: 9AM – 6PM
Tuesday: 9AM – 6PM
Wednesday: 9AM – 6PM
Thursday: 9AM – 6PM
Friday: 9AM – 6PM
Saturday: By Appointment
Sunday: By Appointment