Appointment Date * First Name * Last Name * Birthdate * Gender * MFOther Health Care # * Street Address * City * Postal Code * Mobile Phone # Business Phone # Home Phone # Email * Please check here if you would like to receive offers, promotions and if we can contact you directly.
Family Physician and Phone Health history, please check any of the following that apply to you CancerStrokeCold soresDiabetesAuto immune diseaseWartsHeart DiseaseBlood disordersSkin conditionsLung DiseaseExcessive scarringSkin sensitivitiesNeck or spine DiseaseHirsutismSeizures Surgical History Alcohol Intake * —Please choose an option—SocialDailyNone Do you smoke * —Please choose an option—YesNo Other Medical Conditions Medications * Allergies * Occupation How did you hear about us FacebookWord of mouthInternetOther WHAT SERVICES ARE YOU INTERESTED IN LEARNING ABOUT? Acne/Acne ScarsBotoxFat reductionLaser hair removalSkincare productsFacial FillersCellulite ReductionHair Loss/ RejuvenationLaser treatmentFace liftingBreast correctionLeg Vein TreatmentStretch MarksHair thinningTummy tuckScar revisionMicrodermabrasion/peelsFat reduction � double chinArm liftBotox for Excessive SweatingImproving skin toneNose AugmentationBotox for TMJSkin tighteningLip AugmentationBotox for MigrainesMicro-needlingEyelash Growth (Latisse)Mole Removal What is the main reason for your visit today? * Have you had a consultation or treatment for a cosmetic procedure before? YesNo How often do you think about wanting a cosmetic procedure? Most daysWeeklyMonthly How do you feel that you look relative to your age? OlderYoungerMy Age Which three statements best reflect how you would like to look and feel after the treatment? I want to look less tiredI want to look less angryI want to look less sadI want a less saggy appearanceI want to look more youthfulI want to look more attractiveI want my face to look slimmerI want softer features
I am aware that Dr. Singh may review and discuss this information with health professionals within my circle of care to develop potential goals and care plans.
Note: 48 hour notice is required for any cancellations. A $50 charge will be applied to any missed medical appointments and $100 per 10min charged for any missed cosmetic appointments.
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