Nasseri medical centre

Nasseri Medspa
LAST/ FAMILY NAME: _____________________________ FIRST/GIVEN NAME: _________________________ BIRTHDATE (Day) ___________ (Month) ___________ (Year) ___________ SEX: (M) _______ (F) _______ CARE CARD # ________________________________________________________________________________ MARITAL STATUS: ________________________________ NAME OF SPOUSE: _________________________ OCCUPATION: ________________________________________________________________________________ STREET ADDRESS: _____________________________________________ APT# _____________________ CITY: _________________________________________________________ POSTAL CODE: _____________ HOME PHONE # __________________________ BUSINESS PHONE # _______________________________ CELL PHONE # ___________________________ EMAIL ADDRESS: _________________________________ PERSON TO CONTACT IN CASE OF EMERGENCY: __________________________________________________ PLEASE INDICATE THE METHODS OF CONTACT YOU PREFER: PAST MEDICAL HISTORY:
Medical History (e.g. cancer, diabetes, pacemaker, etc.) ________________________________________________ _____________________________________________________________________________________________ Surgical History: _______________________________________________________________________________ Medications and Natural Supplements: ______________________________________________________________ Allergies: _____________________________________________________________________________________ Do you have any chronic skin conditions? YES ____________________________________________________ Are you taking Aspirin, Pradex or Warfarin? __________________________________________________________ 205-2773 Barnet Highway, Coquitlam, BC V3B 1C2 Nasseri Medspa
You May NOT Have Botox or Fil ers if you are pregnant, breastfeeding, or three months delivery.
Are you using any facial creams containing retinoic acid or retinol? Facial skin products currently being used: ___________________________________________________________ HOW DID YOU HEAR ABOUT OUR MEDSPA?
DOCTOR’S REFERRAL (print name): ___________________________________________________________ FRIEND/CURRENT PATIENT (print name): ______________________________________________________ ATTENDED SEMINAR (print date/location): ______________________________________________________ ARTICLE/ADVERTISEMENT (indicate publication): ________________________________________________ OTHER (please explain): _____________________________________________________________________ GENERAL INFORMATION
Current Family Physician:________________________________________________________________________ I have read and understand all of the above information and have answered the questions accurately and honestly to the
best of my ability.
Signature: ______________________________________________ Date: _____________________________
205-2773 Barnet Highway, Coquitlam, BC V3B 1C2

Source: http://nasserimedical.drnasseri.com/wp-content/uploads/2011/07/MedSpa-Patient-Registration-Health-Form-2012-V2.pdf