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Lotus
@
QUEENSWAY MEDICAL
A Physician-Led Clinic
(416)-238-6773
1066 The Queensway, Etobicoke, ON M8Z 1P7
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Patient Health and Consent Form
First Name
Email
Last Name
Phone
Address
Birthday
Your Family Physician
Do you plan pregnancy within the next two years (if applicable)
Choose an option
How do you want to be notified for your appointment?
Choose an option
How did you hear about us?
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Past medical history.
Current medication
Allergies
Have you ever had any of the following skin conditions?
Acne
Warts
Eczema
Psoriasis
Hyper/Hypo Pigmentation
Scarring
Facial Spider Veins
None
Have you previously had:
Botox / Neotoxins Injection
Fillers
Facial laser
Skin tightening
Facial peel
Microdermabrasion
Facial Spider Veins Treatment
Laser Hair removal
Facial surgery
PRP
None
Your concerns:
Loose skin
Red spot
Excessive sweating
Facial Spider Veins
Laser Hair removal
Uneven skin surface
Wrinkles
Other
Have you had any reaction from previous treatments?
Yes
No
Do you have a history of:
Lupus
Polymyositis
Hemophiles
Rheumatoid arthritis
Multiple sclerosis
Muscular Dystrophy
None
Acknowledgment, Authorization
I understand and accept the less common complications, including the remote risk of death or serious disability that exists with this procedure.
I am aware that smoking during the pre and post-operative periods could increase chances of complications and increase healing time
I have informed the doctor of all my known allergies, including allergies to latex
I have informed the doctor of all medications I am currently taking including prescriptions, over the counter medications/remedies, herbal therapies and any other treatments I am currently doing
I am aware and accept that no guarantees regarding the result of this procedure have been made or implied. I am aware that this procedure is completely voluntary, and treatment is not necessary. Alternative treatments include but are not limited to: doing nothing, cosmetic surgery, laser treatments, chemical peels, and Botox
Prices are subject to change. The pricing I receive during this treatment is only for today's treatment. Any additional treatments, products or services will be billed at rates effective at time of the additional treatments
I am not currently pregnant or nursing
I certify that I have read and understand this agreement and that all spaces for initials were filled prior to my signature.
Read here our privacy policy
Your Signature
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Today's date
Physician Signature
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Signed date
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