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Opulence Experience Intake Form

General Information

First name

Last name

Date of birth

Age

Gender

Male

Female

Non-Binary

Address

Suite/Unit/Apt.

City

State

Zip

Medical History

Please check any of the following medical conditions that apply to you:

Medical Conditions

Neurological Disorders (i.e. Seizures, MS, etc.)

Blood Disorders (i.e. Hemophilia, Excessive Bleeding, etc.)

Autoimmune Disease (i.e. Lupus, Rheumatoid Arthritis, etc.)

Skin Infections (i.e. Cold Sores, Shingles, Rashes, Psoriasis, etc.)

Pregnancy or Breastfeeding

Chemotherapy or Radiation Therapy

No Medical Conditions

Other

Medical Conditions Requiring Antibiotics Before Dental Procedures

Heart Valve Replacement

Joint Replacement

None

Other

Do You Have Any Allergies Including Lidocaine?

Have You Ever Experienced An Allergic Reaction to Any Cosmetic or Medical Products or Procedures?

What areas are you interested in treating with Dermal Filler or Neurotoxin?

By signing below, I certify that I have reviewed and accurately completed this form to the best of my knowledge. I understand that failure to disclose any medical history, current medical conditions, or medications may result in complications during or after the procedure.

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First & Last name

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