Skin Above Vitality Intake Form – Dulwich Hill Chiropratic & Therapeutic Centre

Patient Details

Date of first visit

Title

First Name

Surname

Date of birth

Date (dd)

Month (mm)

Year (yyyy)

Emaila valid email

Address

Suburb

Postcode

PhoneHome

PhoneWork

PhoneMobile

Occupation

Referred Byif applicable

Emergency ContactFull name and contact number

0 /

Private Health Insurance ProviderCompany name or None

What is the main reason for your visit?

0 /

How did you hear about us?

0 /

Health & Medical Information

Are you currently taking any blood-thinning medications?Add details

0 /

Are you currently pregnant or breastfeeding?Female Patients

NoPregnantBreastfeeding

Do you have any allergies to medications? If so, please list them:Add details

0 /

Have you ever undergone any cosmetic procedures in the past?

YesNo

If Yes - Please list them below:Add details

0 /

Facial/ Skin Concerns

Please tick the areas of concern regarding your skin or appearance:

Wrinkles/fine linesAcne or acne scarsSkin tone/textureLoss of facial volumeDark circles or puffinessOther (please specify):

Body Dysmorphic Disorder Screening (BDDQ)

This section is designed to better understand how you view and feel about your appearance. Please answer honestly and thoughtfully.

Do you ever feel concerned about how you look?

YesNo

Do you find yourself thinking about your appearance more than you'd like to?

Yes, I often wish I could think about my looks lessNo, I don’t spend a lot of time thinking about my appearance

Are there specific areas of your body that you’re dissatisfied with? (e.g., skin, hair, nose, mouth, breasts, etc.) *

0 /

Do you worry about not being thin enough, or gaining weight?

YesNo

How much of your daily life is impacted by concerns about your appearance? (Please describe briefly)

0 /

On average, how much time do you spend thinking about your appearance in a day?

Less than 1 hour1-3 hoursMore than 3 hours

Photography Consent

As part of our treatment process, we take “before” and “after” photos to showcase the results of your treatments. These images help us monitor your progress and demonstrate outcomes to potential future clients.

Rest assured, all photos will be stored securely, and any identifiable features will be kept private.

How would you like us to handle your photos?

I’m happy for the clinic to use my photos for marketing purposes.I only consent to the photos being kept for medical records.

Cancellation Policy

We understand that life can take you into unexpected turns, but if you cannot make your appointment time, please call and inform us as soon as possible.

At least 24 hours notice is appreciated. This gives patients on our waiting list an opportunity to book in. Thank you for your understanding.

Missed/Cancelled appointments without appropriate notice will be charged in the following way.

Once is accepted without charge, but please ensure you reschedule appropriately where your appointment will hopefully not be impacted.
On a second missed appointment we request that you pay half of the fee.
On a third missed appointment we will request a full fee rate for that time and future appointments will have to be made on the day you wish to come in.

Please read and agree to the informed consent

By submitting this form, you confirm that the information provided is accurate and that you consent to the terms outlined.

I have read and agree

Yes

Full Name of person who agrees to conditions

Relationship

PatientParentGuardian