Name: 1 Smile Wellness & MedSpa
Address: 41 US Highway 41, Schererville, IN, 46375-1201, US
Telephone: (872) 362-5447

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41 US Highway 41, Schererville, IN 46375

Call Us Today!

(872) 362-5447

Patient Intake Form

First name

Birthday

Last name

Phone

Address

Reason for a visit:

Weight Loss

Facial Fillers

Something Else

Height (ft.)

Height (in.)

Weight

Gender Identity

Race

Martial Status

Medical History

Allergies

Medications

Chronic Medical Conditions

Previous Surgeries

History of Seizures or Eating Disorders

History of Cardiovascular Disease or Any Other Chronic Condition

Additional Questions:

Do you have a current primary physician? *

Yes

Do you have allergies to any medicine? *

Yes

If you have allergies to any medicine, please list them below:

Do you have any chronic diseases? (ex. heart/kidney/liver/thyroid/cancer etc) *

Yes

Do you have a personal history of Pancreatitis? *

Yes

Do you have a family history of thyroid cancer? *

Yes

Do you have a family history of Multiple Endocrine Neoplasia? *

Yes

Have you ever taken weight loss medication? *

Yes

What is your lowest adult weight?

What is your weight goal?

Were you referred? If so, by who?

Are you pregnant? *

Yes

Are you actively attempting to become pregnant? *

Yes

Are you attempting to become pregnant within the next 3 months? *

Yes

Consultation fee

I agree to pay $99 for the consultation and acknowledge my responsibility for any additional fees associated with the transaction.

Upon selecting "Request a Consultation," kindly avoid refreshing your browser, as the procedure may take a few minutes.

Thank you for your submission!

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Schererville Medical Spa | Medical Spa in Schererville | Medical Spa Schererville

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