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Intake Form

Please fill out the information below.

Venus Intake Form

There exists a risk if our staff is not aware of the general health and medical background of a client. This information may critically affect what procedure we may recommend or safely undertake. Please provide us with the following information and keep it updated.

Please select all of the following medical conditions you now have or have had in the past. If you have had none, please select “none of the above”.
Are you a smoker?
Is there any possibility that you may be pregnant at this time?
Do you have a history of cold sores?
Do you or your family have a history of atypical moles, vitiligo, developing keloids, melanoma, or skin cancer?
Have you or anyone in your family ever had, or currently have, a history of unusual reactions or problems with LOCAL anesthesia (e.g. dental freezing), TOPICAL anesthesia (e.g. anesthetic creams or gels) resulting in rashes, muscle weakness, jaundice, breathing problems, and/or unexpected fever(s)?

Thanks for submitting!

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