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657 E. Golf Road, Suite 305, Arlington Heights, IL 60005

For Free Consultation: 847-309-6467

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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?

Yes

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

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

Women Only/ Any hormonal changes or therapy?

Yes

Women Only/ Are you pregnant pr breastfeeding?

Yes

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

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Questions and Free Consultation

847-309-6467

info@lademedspa.com

LOCATION
657 E.Golf Road, Suit 305, Arlington Heights, IL60005

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Medical Form

Refund Policy

Accessibility Statment

Terms and Conditions

Opening Hours

Monday Closed

Tues- Fri 10:00 am- 7:00 pm

Saturday 10:00 am- 4:00 pm

Sunday By an appointment

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