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Mahogany Oasis Aesthetics & Wellness
New Patient Information Questionnaire

Personal Information

Biological Sex
Is your general health good?
Allergies?
Do you take Aspirin, Ibuprofen (Advil, Motrin), Acetaminophen (Tylenol), Naproxen (Aleve) or any other pain or anti-inflammatory medication more than once per week?
Do you consume alcohol?
Do you consume alcohol?
Do you smoke?
Do you regularly use a tanning bed or expose yourself to the sun?
Do you regularly take vitamins?
Are you currently pregnant?
Are you currently trying to become pregnant?
Are you breastfeeding?

Medical History

Have you ever had any of the following? Please check all the apply.
Ehlers-Danlos Syndrome
Cancer
If so, are you still being treated?

To the best of my knowledge, the information provided above is true and accurate. I agree to tell the staff of any changes to my health history or medications as they arise. I understand that information is necessary for your practice and will remain confidential.

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All efforts are routinely made to ensure privacy is upheld:

Thank you! We’ll be in touch.

Please complete forms. If information is not available, please indicate N/A.

WALK-INS

Yes

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PARKING

Free Parking

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SPOKEN LANGUAGE

English

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APPOINTMENT CANCELLATION POLICY

Appointment reminder emailed 48 hours prior to scheduled appt. Cancellations of less than 45 hour notice will result in a 50% charge of the scheduled service.

BUSINESS TYPE

Medical Spa​

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AMENITIES

 TV

 

​~~NO Kids~~

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Phone:

260.450.5914

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

~~~CLOSED

Please 

see VAGARO

and Instagram

for most

current

 availability of hours

The Naked Pineapple 9614 Lima Rd

Fort Wayne, IN 46818

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