Intake Form | Sea Glass Med Spa

SEAGLASS MED SPA INTAKE FORM

We are so excited you've booked with us and can't wait to provide you with an amazing experience! To ensure we tailor every detail to your desires and exceed your expectations, please take a moment to fill out the form below. If you have any questions, please don't hesitate to reach out—we're here to make your experience perfect.

Do you have a BMI >27?

Do you visit your doctor annually?

Yes

Have you had basic labs done in the last year (CBC, CMP, cholesterol, A1C, and TSH/T4)

Do you have a history of high blood pressure, kidney concerns, gall stones, pancreatitis, Methylenetetrahydrofolate reductase (MTHFR) gene mutation, diabetes or thyroid issues?

Unstable mental health, depression or eating disorders?

Personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)?

Pregnant or breastfeeding?

If you are of child bearing age, how are you preventing pregnancy?

Do you drink more than 1 drink per day OR more than 7 drinks per week (woman 2 drinks per day OR more than 14 drinks per week (man)

Thanks for submitting!