Caché Aesthetics

Confidential Client / Clinical Record

New Client / Patient Intake

Please complete and review this required clinical document carefully before signing.

Client

Version

1.1

Status

Awaiting Completion

Section 1

Client Registration & Contact Information

Please provide accurate information so Caché Aesthetics can maintain a safe, complete and current client record. Update the practice whenever important information changes.

Legal Name*Preferred Name / Name UsedDate of Birth*Pronouns (optional)Home Address*City / Parish*Postal CodeMobile Phone*Email AddressPreferred Contact MethodOccupation (optional)Primary Care Physician / GP (optional unless clinically required)Preferred Pharmacy (optional)How did you hear about Caché Aesthetics?

Section 2

Emergency Contact

Provide a person Caché Aesthetics may contact when reasonably necessary for your safety or urgent care.

Emergency Contact Name*Relationship*Emergency Contact Phone*Alternate Phone

Acknowledgements

I confirm the emergency contact above may be contacted if reasonably necessary for my safety or urgent care.

Section 3

Account & Communication Preferences

Appointment and service communications are separate from optional promotional marketing.

I would like or already use a secure My Caché client account.I would like appointment confirmations and reminders by email.I would like appointment confirmations and reminders by SMS / text.

Acknowledgements

I understand promotional or marketing communications require a separate optional consent and are not required for treatment.I confirm that the information provided in this intake form is accurate to the best of my knowledge.I understand I am responsible for updating Caché Aesthetics when relevant information changes.

Authentication

Signature

Review the completed document before signing. Electronic signatures are tied to this specific form and version.

Signature & Authorization

Patient Signature

Choose how you would like to sign this form.

Full Legal Name

Signature Preview

Patient Signature

I confirm that this signature is mine and I intend it to serve as my electronic signature for this form and version.

Privacy, Health & Consent

Digital-first and printable

New Client / Patient Intake

Client Registration & Contact Information

Emergency Contact

Account & Communication Preferences

Signature

Patient Signature