Appointment Agenda

Dear Patient: We know that your time is invaluable! In order to address your healthcare concerns today,
please complete the questions below:

Name(Required)

First Last

Phone(Required)

Email(Required)

A) What are the two main things you would like us to focus on and get done for you today?

B) What are other things you would like us to take care of today (if there is time) or schedule a future visit (if there isn’t time):

Have you been to urgent care, emergency room or been hospitalized since your last office visit?

Yes

If yes, where:(Required)

Have you seen any specialists since your last office visit?

Yes

If yes, please list them.(Required)

Have you had any tests by a specialist since your last office visit?

Yes

If yes, please list them.(Required)

Check all that apply:

I need some prescriptions refilled

My pharmacy has changed

I need some forms filled out today

I need a school or work excuse

My insurance has changed

I have chest pain or tightness

I would like to get some help losing weight and staying healthy

I feel depressed and would like some help

I would like to get tested for sexually transmitted diseases

I am interested in Hormone replacement

I am interested in treatment for Opioid Use Disorder

Clearwater Aesthetics Appointment Agenda

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