Client Preparation

Beauty by Fox Medical Questionnaire

Please answer every question carefully and completely. Your responses will be reviewed by Maritza Fox before your procedure. Completing this questionnaire and the remaining intake documents does not confirm medical eligibility or approval for treatment.

Beauty by Fox Medical Questionnaire

Your Information

First Name *

Last Name *

Email Address *

Mobile Phone Number *

Date of Birth *

Medical History

Additional Details

Please explain all Yes answers. *

Include the condition, medication, treatment, relevant dates, and anything else Maritza should review. If you answered No to every question, type "None."

Certification and Signature

I certify that the information provided in this medical questionnaire is complete and accurate to the best of my knowledge. *

Signature *

Sign using your finger on mobile or mouse on desktop.

Sign here using your finger or mouse

Type Your Full Legal Name *

Need Help With Your Questionnaire?

If you cannot open the questionnaire, have trouble submitting, or have questions about the intake process, please contact Beauty by Fox.

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