Confidential
Intake Form

Name *
Name
Phone *
Phone
Are you a new lifestyle patient at Med1? *
Have you received aesthetic treatment at Med 1 Aesthetics? *
Have you ordered nutraceuticals online from drtromble.com?
Are you a member of Anytime Fitness? *
Are you interested in any or all of the following?
Have you ever hired a Personal Trainer? *
Have you ever tried Medically Supervised Weight Loss? *

Goals

Name *
Name


Additional Forms

Consent to Participate

Name *
Name
TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure, service or treatment. I understand that I will be treated with any of the following: Strength & Conditioning programming, Nutritional Advice, Pharmaceutical Prescriptions, O2 Therapy, Aromatherapy, Cyrotherapy, fitness and health instruction or other. No promises or guarantee has been made to me as a result or my participation. The following risks may occur with injections: bleeding, bruising, redness, pain, scarring, swelling, discoloration, infection, raised bumps of skin (nodules), headache, allergic reactions, poor cosmetic result, cold sores (if had previously), death. These risks are not meant to be all inclusive as there are both known and unknown side effects associated with any medication or procedure. I will follow all care and aftercare instructions. By signing below, I acknowledge that I have read the above informed consent and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent treatments with the above understood and voluntarily participate.
Date *
Date
Please check the box and submit *
I am aware of the associated risks of this treatment plan and take full responsibility. I am also aware of the Med 1 Aesthetics HIPAA Private Policy.