Medical Intake Form | Platinum Beauty Bar

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SUN: 12:00 PM - 5:00 PM

770-800-7500

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Medical Intake Form

First name

Last name

Email

Phone

Date Of Birth

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Are you currently breast feeding?

List all known Allergies

What medications are you currently taking:

Check all that apply?

I have been diagnosed with "Multiple Endocrine Neoplasia Syndrome Type 2" (MEN2)

I have Pancreatitis (inflammation of the Pancreas)

I have Cholecystitis (inflammation of the Gall Bladdar)

I have Asthma

I have Cardiac Disease

I have Hypertension

I have a Psychiatric Disorder (i.e. Bipolar, Schizophrenia, etc.)

I have a history of Epilepsy

I have a history of substance use

I have a history of Thyroid Cancer

I have active Cancer

Have you tried any other weight loss programs to lose weight in the past?:

Check all that apply?

I struggle to lose weight

I have cravings for foods that I shouldn't eat.

I find it hard to exercise because I have no energy

List any health conditions you have or had within the last 6 months.

Contact

Email

info@platinumbbs.com

Phone

(770) 800-7500

Address

1990 Parker Rd. SE

Conyers, GA 30094

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Disclaimer

*3.99% Credit Card Fee Applies

Deposit Disclaimer: All deposits are non-refundable. we are happy to reschedule your service with a minimum of 48 hours advance notice of cancellation.

Late Arrivals: The guest should arrive at least 20 minutes before the first service time. If guests arrive 15 minutes late into the service time, the service time is subject to be abbreviated to avoid delays for other guests. The amount of time that the service will be abbreviated will be determined by remaining scheduled guests and is up to the staff and the therapist or technician discretion; and will be charged full-service value.

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