Please fill out the information below accurately to ensure we can provide the best care tailored to your needs.
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Name: Date of Birth: Address: Phone Number: Email:
Please provide information on any recent treatments you’ve received.
Botox (How recent?): Threads (How recent?): Fillers (How recent?): Facelift (How recent?):
Have you had any of the following treatments in the last month? Chemical PeelsLaser treatmentsMicrodermabrasionPrescriptions
List any prescription creams or oral medications provided by a dermatologist:
Check all that apply: Neck injuriesDental implantPregnantCancerLymph node removedVertigoPacemakerCold soresClaustrophobia
I understand that the services provided by Total Wellness with Erica are non-medical wellness services and are not a substitute for medical care, diagnosis, or treatment. I affirm that I have disclosed all relevant health information accurately and will notify the practitioner of any changes to my health status. I voluntarily consent to receive these services and release Total Wellness with Erica and its practitioner from liability for any adverse reactions resulting from undisclosed or inaccurate information.
I AGREE TO THE ABOVE WRITTEN POLICIES AND UNDERSTAND THIS AGREEMENT AS MY LIABILITY WAIVER AND RELEASE WAIVER FROM ALL TREATMENTS/FUTURE TREATMENTS WITH Erica Coughlin/Total Wellness With Erica.
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