INTAKE FORM I

OccupationName Date

Address Bulsness Name

City Zip Code Date of Birth

o Sng le o Married o Divorced o WIdowed EmailMarital Status ~

Cell Phone Emergency Contact Phone

carrierHow did you hear about us

o Intemet oPrintAd oEmail oSocIal media oFriend (name) o Other

] ~E~bn~ HISTp~y PleQs~checKalth9tapPy _ _ - - ~

o NumbnessTInglin~ oLymph Edema oAllergies

o Rashes I oJaw PalnTMJ o Blood Clots I

oCold Sore I oHerpesShingles oHeadachesNeck or Back Pain I

oBrokenFractured Bones oCancer oChronic Pain

a Breostfeeding a Pregnancy 1__ weeks)I oOther (explain) I

I

Please list any accidents or surgertes you hove hod

Are you 91erglc to qny oral or topical medications DYes oNo If yes please list

Ust of medications you are currently taking -

2 TODAyfS~SIT i

middot What service ore you here for today o Chemical Peel oFacial o Botox o Filler oMassage

DYes oNoHave you ever received this service before

Iffodays v(sH Is for q massage kindly sldp fo section IS middot -

I3 SKiNtAR~middot shyAre you under the qare of a dermatologist DYes oNo

Do you use I o Adapalene oAccutane o Retin A 0 Other prescription skin products

oGlycolic Acid o Retinoic Acid oRenovo 1

Have you hod 0 oChemical Peel 0 Microdermabrasion oBotox oOther resurfacing treatments -- -- shy

4 SKIN MAI~t~~ANC~ _ ~

Products you use oSoap oCleanser oTO(1er oMoisturizer oExfoliator oMasque

Skin Type DOilyCongested DOry oSensitiveRedness oAcne oSunburned

oEczema o Psoriasis

Are you concerned with any of the foilowing o Other please describe

oAcne oRed Spots o Broken Capillaries oRosasea oBrown spots oFine UneslWrinkles

Do you use a tannirig bed DYes oNo Do you use sunscreen DYes o No What are your skin care goals

- -- S_ MAS$A~ElHE~APY ~ middot - --

Is this your first time receiving a massage DYes oNo

What type of pressure do you prefer

Is there any area of your body you do not want massaged PLEASE FlLP OVER THIS PAGE

~Jr~ It C A (9731943-4300 wwwmeccaspacom

I So that we may better serve you please answer the following questions I

Whenlooldng at my face in the mirror I believe I look

Younger than my age i

I am bothered by

unwahted hair on facebody

Redness in my face

Fine and wrinkles on my face

Crows Feet

Thin Ifps

Wrinkles around my mouth I

Holl9w cheeks

Red v~ins on my face i

Red spots on my I

Deep Hnes on my

Dark Jpots on my facechesthands I

BJemi~hesblackheadswhiteheads

Acne Scars

My true age

J Yes

DYes

DYes

Yes

DYes

DYes

DYes

DYes

DYes

DYes

o Yes

DYes

DYes

than my age

D No

D No

D No

No

D No

D No

o No

D No

D No

o 11J0

D Nomiddot

oNo

D No

Procedures or of interest to you (please check all that apply)

G BOTOX Cosmetic 0 Chemical Peels

I Dermal Fillers (Ie Juvederm Restylane Voluma o Correction of Veins

o o o Sklncare

o Other please specify _______o Correction of Sun Damage or

0 Hair Removal

How did you hear about us 0 My physician (full name) ____________________

o A friend orfamily member (full

o Internet

o Other (please listl _____________________

Lightening System for

I Cancellations within 24 hours ofscheduled appointment are subject to a $2500 cancellation fee

I I

Patiert

~Jr~ It C A (9731943-4300 wwwmeccaspacom

I So that we may better serve you please answer the following questions I

Whenlooldng at my face in the mirror I believe I look

Younger than my age i

I am bothered by

unwahted hair on facebody

Redness in my face

Fine and wrinkles on my face

Crows Feet

Thin Ifps

Wrinkles around my mouth I

Holl9w cheeks

Red v~ins on my face i

Red spots on my I

Deep Hnes on my

Dark Jpots on my facechesthands I

BJemi~hesblackheadswhiteheads

Acne Scars

My true age

J Yes

DYes

DYes

Yes

DYes

DYes

DYes

DYes

DYes

DYes

o Yes

DYes

DYes

than my age

D No

D No

D No

No

D No

D No

o No

D No

D No

o 11J0

D Nomiddot

oNo

D No

Procedures or of interest to you (please check all that apply)

G BOTOX Cosmetic 0 Chemical Peels

I Dermal Fillers (Ie Juvederm Restylane Voluma o Correction of Veins

o o o Sklncare

o Other please specify _______o Correction of Sun Damage or

0 Hair Removal

How did you hear about us 0 My physician (full name) ____________________

o A friend orfamily member (full

o Internet

o Other (please listl _____________________

Lightening System for

I Cancellations within 24 hours ofscheduled appointment are subject to a $2500 cancellation fee

I I

Patiert

-----------------------------------------------------------

r

CONSENT FORM It is my choice to receive spa therapies I have completed this form to the best of my knowledge I have stated all medical conditions that 1 am aware of and I will update The Spa at Mecca of any changes in my health status I understand that Aestheticians and Massage Therapists do not diagnose illness disease or physical and mental disorders nor do they prescribe medical treatments pharmaceuticals or perform spinal manipulations I acknowledge that these treatments are not a substitute for a medical examination or diagnosis and that is recommended I see a primary health care provider for that service If I am unable to make a scheduled appointment I agree to cancel the appointment 24 hours in advance by phone unlessl have an emergency In this case I will call ASAP to reschedule my appointment If I miss an appointment without giving 24 hour notice I agree to pay the missed appointment fee that applies

I und~rstand that any illicit or sexually suggestive behavior remarks or advances made by me will result in the immediate termination of the session and I wi ll be liable for payment of the scheduled service

I

I am dlso aware of the cancellation policy which states that in the event that a client need~ to cancel an appointment he or she must do so at least 24 hours before scheduled service Failure to do so wHl result in an automatic charge of $25 dollars

Full Name (Printed]

Signature I ------------------------------------------------------------shy

Date I I

If the patient is a mino please have the legal guardian sign consent in addition to the underage client

Name OfI

ResponsIble Party

Signatur~

Relatio~hlP to client

Patient Testimonial Video Photo Audio Release Consent

Consent to Release I hereby authorize Mecca Integrated Medical Center LLC and staff to use

and disclose my testimonials photos videos and audio recordings in any medium for o

educational promotional advertising andor any other purpose that supports the mission of

Mecca Integrated Medical Center llC

1understand and approve the disclosure of the testimonials photos videos audio information

to the media and other individuals and entities that may be involved in the mediapublic

relations efforts of Mecca Integrated Medical Center LLC I understand that Mecca Integrated

Medi~al Center llC and my treating healthcare provider will not be providing any protected

infor~ation (except first name) to the media or the public including private health information

in m~ medical records the confidentiality of which may be protected by federal and state I

statutes and regulations including the Health Insurance Portability and Accountability Act

(HIPPA) I waive the right of prior approval and hereby release Mecca Integrated Medical

Cent~r lLC from any and all financial compensation andor claims for damages of any kind

base1 on the use of my testimonials pictures videos or audio recordings By signing below I

agre~ and acknowledge that I have read and understand the above release and agree to all

terms described I am of legal age and freely sign this Consent to Release my Patient

Testimonial and Other Media to Mecca Integrated Medical Center lLC

Right to Revoke You have the right to revoke this release at any time by providing written

notice of your revocation and submitting it to the office of the community relations o coordinator Please understand that revocation of this release will not affect any action Mecca

Integrated Medical Center LLC took in reliance on this release before receiving your revocation

Signature _________________________

printIName_________________________

DateI __________ I

PleaL provide your contact information I

IAddrss ______________________________

Phone _____________________

I Emall _______________________________

Patients PrimarY Concern

I

t~

I

Clinical Recommendations

Skin Care

Injactables

Praced u res

Paels

Likelihood of Compliance

IAny Quote Given

)

Patient Concerns NAME__________ DATE___--- shy

EMAIL PHONE_______

Please indicate your areas 0 concern below

Forehead Lines Frown Lines

Yes No

Improve Texture of SkinLarge Pores

Yes No

Factal Volume Loss

Yes No

Nose-to-Mo~th Lines

Yes INo Acne ScaringFacial Scars

I Yes No LipsVolume Loss

Yes No Red SpotsFlushing

Yes No

TextureSaggy

Lip Lines Lipstick Bleed Lines

Yes No

Skin Yes No

I

Are you interested in Skin Care Yes No

Double Chin Turkey Neck

Yes No

Neck and Chest Discoloration

Yes No

Crows Feet

Yes No

Under Eye Circles

linesBags Yes No

Brown SpotsFreckles

Yes No

Broken Blood Vessels 0

Yes No

Clincion Use Only

~gi Up DO(2) -to ~ ~0 l Y +s I ) l ltC-- 0 U rt +s w ~ 111 EOdr -i-eGlfY1E-VLt-- ar PLL(SZ r r ~ ~

BRILLIANT DISTINCTIONS PROGRAM SIGN-UP INSTRUCTIONS

1 Find the Brilliant Distinctions app in your app store on your phone or go to wwwbrilliantdistinctionscom

and pr~ss become a member

2 Enter your information or sign in with FacebookGoogle (see below) Enter your password as ~k-(~ (capital M) so the front desk can access your account to retrieve your points for Allergan services

Join Take the first step towards earning rewards for receiving qualifying treatments and purchasing participating Brilliant DistinctionS products

GOOGLE )

All Fields Required

First NamJ

Last NamJ

Emaill

Password

l SHOW

Your password must contain at least

8 characters 1 uppercase letter 1 lowercase letter 1 number

MobUe - Why is this reqUiredl

r I certify that I am over the age of 18 and by enrolling in the Brilliant Distinction~ Program I agree to the TERMS AND CONDITIONS JOIN TODAY

3 Provide front desk with USERNAME for login purposes Thank you

Patient Testimonial Video Photo Audio Release Consent

Consent to Release I hereby authorize Mecca Integrated Medical Center LLC and staff to use

and disclose my testimonials photos videos and audio recordings in any medium for o

educational promotional advertising andor any other purpose that supports the mission of

Mecca Integrated Medical Center llC

1understand and approve the disclosure of the testimonials photos videos audio information

to the media and other individuals and entities that may be involved in the mediapublic

relations efforts of Mecca Integrated Medical Center LLC I understand that Mecca Integrated

Medi~al Center llC and my treating healthcare provider will not be providing any protected

infor~ation (except first name) to the media or the public including private health information

in m~ medical records the confidentiality of which may be protected by federal and state I

statutes and regulations including the Health Insurance Portability and Accountability Act

(HIPPA) I waive the right of prior approval and hereby release Mecca Integrated Medical

Cent~r lLC from any and all financial compensation andor claims for damages of any kind

base1 on the use of my testimonials pictures videos or audio recordings By signing below I

agre~ and acknowledge that I have read and understand the above release and agree to all

terms described I am of legal age and freely sign this Consent to Release my Patient

Testimonial and Other Media to Mecca Integrated Medical Center lLC

Right to Revoke You have the right to revoke this release at any time by providing written

notice of your revocation and submitting it to the office of the community relations o coordinator Please understand that revocation of this release will not affect any action Mecca

Integrated Medical Center LLC took in reliance on this release before receiving your revocation

Signature _________________________

printIName_________________________

DateI __________ I

PleaL provide your contact information I

IAddrss ______________________________

Phone _____________________

I Emall _______________________________

Patients PrimarY Concern

I

t~

I

Clinical Recommendations

Skin Care

Injactables

Praced u res

Paels

Likelihood of Compliance

IAny Quote Given

)

Patient Concerns NAME__________ DATE___--- shy

EMAIL PHONE_______

Please indicate your areas 0 concern below

Forehead Lines Frown Lines

Yes No

Improve Texture of SkinLarge Pores

Yes No

Factal Volume Loss

Yes No

Nose-to-Mo~th Lines

Yes INo Acne ScaringFacial Scars

I Yes No LipsVolume Loss

Yes No Red SpotsFlushing

Yes No

TextureSaggy

Lip Lines Lipstick Bleed Lines

Yes No

Skin Yes No

I

Are you interested in Skin Care Yes No

Double Chin Turkey Neck

Yes No

Neck and Chest Discoloration

Yes No

Crows Feet

Yes No

Under Eye Circles

linesBags Yes No

Brown SpotsFreckles

Yes No

Broken Blood Vessels 0

Yes No

Clincion Use Only

~gi Up DO(2) -to ~ ~0 l Y +s I ) l ltC-- 0 U rt +s w ~ 111 EOdr -i-eGlfY1E-VLt-- ar PLL(SZ r r ~ ~

BRILLIANT DISTINCTIONS PROGRAM SIGN-UP INSTRUCTIONS

1 Find the Brilliant Distinctions app in your app store on your phone or go to wwwbrilliantdistinctionscom

and pr~ss become a member

2 Enter your information or sign in with FacebookGoogle (see below) Enter your password as ~k-(~ (capital M) so the front desk can access your account to retrieve your points for Allergan services

Join Take the first step towards earning rewards for receiving qualifying treatments and purchasing participating Brilliant DistinctionS products

GOOGLE )

All Fields Required

First NamJ

Last NamJ

Emaill

Password

l SHOW

Your password must contain at least

8 characters 1 uppercase letter 1 lowercase letter 1 number

MobUe - Why is this reqUiredl

r I certify that I am over the age of 18 and by enrolling in the Brilliant Distinction~ Program I agree to the TERMS AND CONDITIONS JOIN TODAY

3 Provide front desk with USERNAME for login purposes Thank you

Patients PrimarY Concern

I

t~

I

Clinical Recommendations

Skin Care

Injactables

Praced u res

Paels

Likelihood of Compliance

IAny Quote Given

)

Patient Concerns NAME__________ DATE___--- shy

EMAIL PHONE_______

Please indicate your areas 0 concern below

Forehead Lines Frown Lines

Yes No

Improve Texture of SkinLarge Pores

Yes No

Factal Volume Loss

Yes No

Nose-to-Mo~th Lines

Yes INo Acne ScaringFacial Scars

I Yes No LipsVolume Loss

Yes No Red SpotsFlushing

Yes No

TextureSaggy

Lip Lines Lipstick Bleed Lines

Yes No

Skin Yes No

I

Are you interested in Skin Care Yes No

Double Chin Turkey Neck

Yes No

Neck and Chest Discoloration

Yes No

Crows Feet

Yes No

Under Eye Circles

linesBags Yes No

Brown SpotsFreckles

Yes No

Broken Blood Vessels 0

Yes No

Clincion Use Only

~gi Up DO(2) -to ~ ~0 l Y +s I ) l ltC-- 0 U rt +s w ~ 111 EOdr -i-eGlfY1E-VLt-- ar PLL(SZ r r ~ ~

BRILLIANT DISTINCTIONS PROGRAM SIGN-UP INSTRUCTIONS

1 Find the Brilliant Distinctions app in your app store on your phone or go to wwwbrilliantdistinctionscom

and pr~ss become a member

2 Enter your information or sign in with FacebookGoogle (see below) Enter your password as ~k-(~ (capital M) so the front desk can access your account to retrieve your points for Allergan services

Join Take the first step towards earning rewards for receiving qualifying treatments and purchasing participating Brilliant DistinctionS products

GOOGLE )

All Fields Required

First NamJ

Last NamJ

Emaill

Password

l SHOW

Your password must contain at least

8 characters 1 uppercase letter 1 lowercase letter 1 number

MobUe - Why is this reqUiredl

r I certify that I am over the age of 18 and by enrolling in the Brilliant Distinction~ Program I agree to the TERMS AND CONDITIONS JOIN TODAY

3 Provide front desk with USERNAME for login purposes Thank you

~gi Up DO(2) -to ~ ~0 l Y +s I ) l ltC-- 0 U rt +s w ~ 111 EOdr -i-eGlfY1E-VLt-- ar PLL(SZ r r ~ ~

BRILLIANT DISTINCTIONS PROGRAM SIGN-UP INSTRUCTIONS

1 Find the Brilliant Distinctions app in your app store on your phone or go to wwwbrilliantdistinctionscom

and pr~ss become a member

2 Enter your information or sign in with FacebookGoogle (see below) Enter your password as ~k-(~ (capital M) so the front desk can access your account to retrieve your points for Allergan services

Join Take the first step towards earning rewards for receiving qualifying treatments and purchasing participating Brilliant DistinctionS products

GOOGLE )

All Fields Required

First NamJ

Last NamJ

Emaill

Password

l SHOW

Your password must contain at least

8 characters 1 uppercase letter 1 lowercase letter 1 number

MobUe - Why is this reqUiredl

r I certify that I am over the age of 18 and by enrolling in the Brilliant Distinction~ Program I agree to the TERMS AND CONDITIONS JOIN TODAY

3 Provide front desk with USERNAME for login purposes Thank you

Jr ( ( ((

(tIIlY _middot middot

t r

~CareCredif

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