Bloom Health | History Form

Have you had any type of treatment for underchin fullness in the past?

Have you had any type of surgery on your underchin or neck area in the past?

CoolSculpting is a treatment that eliminates stubborn fat noninvasively. Similar to Kybella—it’s FDA cleared for treatment of submental fullness. Would you like to learn more about CoolSculpting during your visit?

Is your underchin treatment in preparation for an upcoming event (e.g. wedding, vacation, etc.)? If so, how long until the event?

Underchin treatment can require anywhere from 3-6 sessions of Kybella to achieve the desired result. Have you planned how many sessions of Kybella you'd like to receive?

What types of skincare products do you use in your usual skincare routine?

Have you used any of the following types of corrective skincare products in the past?

Do you have a preference for any specific collections of medical grade skincare?

Have you ever had an allergic reaction to any of the following?

Do you take any supplements or medications that thin the blood?

Are you pregnant or trying to become pregant?

Are you nursing?

Do you consent to photos being taken in order to monitor the results and progress of your treatment?

Do you give permission to Bloom Health to use your photos publicly for educational or promotional purposes?

How'd you hear about us?

HIPAA PRIVACY NOTICE

Bloom Health maintains compliance with the Health Insurance Portability and Accountability Act (HIPAA). HIPAA provides certain rights and protections to you as the patient, including protection of your Personal Health Information (PHI). HIPAA sets forth rules and restrictions on who has access to your PHI. If you'd like to view our HIPAA policy in its entirety, please click here.

GENERAL CONSENT TO TREATMENT

By entering my initials below, I verify that I have read and fully understand this questionnaire. I have responded to the questions truthfully. I understand that withholding information or providing misinformation may result in unforeseen side effects or complications. I am aware that it is my responsibility to inform BLOOM HEALTH and my treating provider of any updates to my health history. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. While all treatments are recommended to achieve the best possible results, I understand that not all treatments will have the same result for every client, therefore no guarantee can be given. The treatments I receive from BLOOM HEALTH are voluntary and I release BLOOM HEALTH, PLLC from liability and assume full responsibility thereof.

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