Get Intake Form

Completing the Intake Form online is an essential step in helping us understand your needs and medical history. This guide provides user-friendly instructions to make the process straightforward and efficient.

Follow the steps to successfully complete your Intake Form.

1. Press the ‘Get Form’ button to access the Intake Form and open it in the editor.
2. Begin by entering your personal information in the designated fields. This includes your name, date of birth, age, occupation, home address, and contact details. Ensure that all entries are accurate and up to date.
3. Provide an emergency contact’s name and phone number. This information will be used only in case of emergencies.
4. Indicate how you found us by selecting the appropriate option. This helps us improve our services.
5. Fill out the medical history section carefully. Answer whether you are currently under a physician's care and specify the conditions if applicable. Mark 'YES' or 'NO' for the various medical conditions listed.
6. Indicate if you are pregnant, trying to conceive, or using contraception, as this information is crucial for your treatment.
7. List any medications you currently take, including prescription medications and supplements. Be thorough to ensure we can provide the best care.
8. Complete the facial history section by describing any concerns regarding your facial appearance and your expectations for your visit.
9. Answer the questions regarding any facial injuries, trauma history, and whether you are enrolled in the Brilliant Distinctions Program.
10. Finally, read and sign the certification and consent sections regarding medical history accuracy and photo usage. Ensure that you date your signature.
11. After filling out the form, you can save your changes, download a copy for your records, print the form, or share it as needed.

Get started by completing your Intake Form online today.