Conceirge Client Intake Form

Thank you for booking a concierge appointment with us! We can't wait to treat you. Prior to your treatment, we require you to complete the below form in it's entirety to ensure we are meeting all safety guidelines and treating you in the best way possible!

First name

Last name

Birthday

Phone (enter 1 before your area code)

Date

Address at which you will receive treatment (must be within 25 miles of our office)

Allergies

Medical Conditions/Medical History

Current Medications (include supplements as well)

Previous Surgeries

When was the last time you had Botox or Dysport?

When was the last time you had dermal filler?

By signing this agreement and completing the form, I acknowledge that the information I have provided to Bullock Center for Aesthetics is accurate and truthful to the best of my knowledge. I consent to the terms outlined and confirm that I have fully understood the contents of this agreement.

Signature

Completing this form does not guarantee you will be an approved candidate for our concierge services. Upon receiving the submitting form, our physician will review your medical history and either approve our decline the treatment. You will be contacted either way. Please allow 48 hours after submission for your request to be processed. Should this form not be completed in its entirety, this may result in cancellation of your service or need to reschedule.