top of page

HOME
MEDICAL AESTHETIC
WELLNESS
ABOUT
CONTACT
WEBINAR

Back to Booking

Health declaration

Please fill out the following form.

First name

Last name

Email*

Phone

Address

Date of birth

Month

Day

Year

Emergency Contact/ Relationship/ Phone Number

Primary Care Information/ Primary Care Physician:

Phone of Primary Care Physician/ Date of Last Physical Exam:

Allergies.

No Known Drug Allergies

If Yes, list any medication, food , or latex allergies:

If you answered yes to any allergies, please supply additional information.

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Current Medications/ List any medications you are currently taking including the counter medication.

Surgical History/ List any surgeries or hospitalizations(with dates):

Women Only/ Using Birth Control?

Yes

No

Women Only/ Any hormonal changes or therapy?

Yes

No

Women Only/ Are you pregnant pr breastfeeding?

Yes

No

Skin type( Fitzpatrick Scale)

Current skincare routine/products:

History of cold sores?

History of keloids or scarring?

Have you had any of the following treatments in the last 4 weeks?

Botox

Fillers

Laser

Microneedling

Chemical Peel

Waxing

Other

Primary Concern/ Reason for Visit:

Tobacco use

If Yes, How often?

Alcohol Use

If Yes, Frequency?

Recriational Drugs

If Yes, What Type?

Initials*

I declare that the info I’ve provided is accurate and complete.

I will inform Ladé Med Spa, LLC of any changes to my health status or medications before future treatments.

Date

Month

Day

Year

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Ladé Med Spa

Don't Wait Until You're Sick to Take Care of Your Health.

At Lade Med Spa, we help busy professionals prevent chronic disease, lose weight sustainably, improve energy and age naturally through personalized wellness program and aesthetic treatments care.

Book Your Free Consultation

Quick Links

Home
About Us
Services
Book Consultation
Contact Us

View Map

Contact us

847-309-6467

Info@lademedspa.com

657 E. Golf Road, Suite 305
Arlington Heights, IL60005

Operating Hours

Sunday & Monday - Closed

Tuesday - Friday: 10:00 Am- 7:00 Pm

Saturday: 9.00am – 2:00 pm

bottom of page