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PAYMENT PLANS
ABOUT
CONTACT
BOOKING
Information About You
Patient Name
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First Name
Last Name
Today's Date
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
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Phone
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Email
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Occupation
Sex at Birth
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Female
Male
Gender Identity
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Female
Male
Identity Preference
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She/Her
He/Him
They/Them
How did you hear about us?
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Friend/Family
Instagram
Facebook
Other
Provide more information on how you heard about us
Emergency Contact
Emergency Contact's Relation To You
Emergency Contact's Phone
(###)
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Information About Your Health
Are you currently under the care of a physician?
Yes
No
Are you currently under the care of a dermatologist?
Yes
No
Does anyone in your family have a history of melanoma or other skin cancer?
Yes
No
If Yes, Who?
Are you pregnant or trying to become pregnant?
Yes
No
Have you had any of the following surgical procedures?
Check all that apply
Heart Valve Replacement
Joint Replacement
Pacemaker
Defibrillator
Have you ever had any allergies to food or medications?
Check all that apply
Food
Aspirin
Hydrocortisone
Latex
Lidocaine
Hydroquinone
What oral medications are you presently taking?
Please include all non-prescription herbs and supplements
Have you ever used Accutane?
Yes
No
If Yes, when did you last use it?
What topical medications or creams are you currently using?
Do you use tobacco, chew, snuff or marijuana?
Yes
No
If Yes, what type, how often?
Do you consume alcohol?
Yes
No
If yes, how much and how often?
Do you have any problems with allergies or your immune disorders?
Yes
No
Are you under significant stress?
Yes
No
Do you have any problems with scarring?
Yes
No
Do you have problems with bleeding?
Yes
No
Do you have any of the following medical conditions?
Please check all that apply
Cancer
Diabetes
Anxiety
Herpes
Arthritis
Cold Sores
HIV/AIDS
Keloid Scarring
Skin Disease
Skin Lesions
Seizures
Hepatitis
Depression
Blood Clotting
Active Infection
Heart Attack
Stroke
Hearing Loss
Leukemia
Lymphoma
Hormone Imbalance
High Blood Pressure
Thyroid Imbalance
Artificial Joints
End Stage Renal Disease
Have you ever had any of the following skin diseases?
Please check all that apply
Actinic Keratoses
Melanoma
Basal Cell Carcinoma
Squamous Cell Carcinoma
Which of the following best describes your skin type?
Select one
Always burns, never tans
Always burns, sometimes tans
Sometimes burns, always tans
Rarely burns, always tans
Brown, moderately pigmented skin
Black skin
How Can We Help You With Your Cosmetic Needs?
Please describe the primary concern that you are coming in to seek treatment for write the desired treatment:
Are you interested in learning about any of the following treatments that we o er to help you achieve your aesthetic goals?
Foundation
Check all that apply
Cleansing Facial
Acne Facial
JetPeel Hydrator
JetPeel Nip&Tuck
Wake up Facial
Vi Peel
PCA Sensi Peel
Fill
Check all that apply
Dermal Filler
Botox
Dysport
Finish
Check all that apply
Laser Hair Removal
Skin Rejuvenation
Morpheus 8
Lumecca (IPL)
Forma
Clear and Brilliant
Regenerative Medicine
Check all that apply
Plasma Pen
Orgasm/Priapus Shot
Platelet Rich Plasma (PRP)
HD PDO Threads
Vampire Facial
Sweat-Less
Financial Policy and Agreement
Vivant Aesthetics, Inc is committed to providing patients with quality medical care and an enjoyable patient experience. As a patient you have the responsibility of knowing the cost of your medical treatment.
Payment for Treatments
Payment for treatments are not covered by insurance and is full on the day of service. We accept payment in the form of cash, Visa, Mastercard, Discover, American Express, and Care Credit.
Treatment Packages
Patients may wish to purchase a package of treatments in order to receive a discount. Patients may only purchase packages once they have been evaluated and it has been determined that they are a good candidate for the treatment. Packages may be paid in full, or in two installment payments 1st treatment and 2nd treatment.
Refunds
There are no refunds on services, unless otherwise determined by Management. There are no cash/credit back refunds. If Management determines that compensation is appropriate, the Client will receive an in house gift card for an estimated dollar amount. Service Providers are not permitted to grant refunds at any time.
Cancellation Policy
Cosmetic appointments must be cancelled 24 hours in advance in order to avoid a cancellation fee of $25 for 30 minutes or $50 for 60 minute appointments. Cancellation fees are e ective within the 24 hour window of the appointment, and does not apply to any procedures.
I have read, understand, and agree to the Financial Policy above and understand any final obligations for payment are mine.
*
Yes
Thank you!
