Med Spa Patient Intake Form Template
Med spas offering weight loss, peptide therapy, and hormone optimization programs need intake forms that bridge aesthetic services and medical care. This template is designed specifically for med spas adding cash-pay medical programs alongside their existing aesthetic services. It captures the clinical information required for prescribing weight loss medications (GLP-1s), peptides, and hormone therapy while maintaining the streamlined patient experience med spa clients expect. The form covers medical history, aesthetic and medical treatment goals, contraindication screening, and the specific consent elements required for med spa medical services under physician supervision.
Form Preview
Section 1 of 5
Patient Information
Please provide your contact information.
Full Name *
Jane Smith
Date of Birth *
...
Phone *
(555) 000-0000
Email *
Address *
123 Main St, City, ST 00000
Preferred Contact Method
Text
Section 2 of 5
Services of Interest
What brings you in today?
Which services are you interested in? (select all)
Primary Goal *
Weight loss
Section 3 of 5
Medical History
Please check any conditions you have or have had.
Current Medical Conditions
Current Medications *
List all medications and supplements
Allergies *
Medications, foods, latex, topical products
Are you pregnant, breastfeeding, or planning pregnancy?
Smoking / Tobacco Status *
Never
Previous aesthetic treatments (Botox, fillers, laser, etc.)
List previous treatments, dates, and any complications
Section 4 of 5
Physical Assessment
Your current measurements.
Current Weight (lbs)
165
Height
5'5"
Goal Weight (if applicable)
140
Section 5 of 5
Referral & Payment
A few final details.
How did you hear about us?
Online search
These programs operate outside of insurance, giving you and your provider full control over your treatment plan. Are you comfortable with a direct-pay model?
This is a preview. Actual form will be customized with your practice branding.
Compliance & Regulatory Notes
Med spas must operate under the supervision of a licensed physician per state medical board regulations. The supervising physician's name and license number should be displayed on all patient-facing documents. State supervision requirements vary; see your state medical board for specifics.
Med spa services that involve prescribing medications (GLP-1s, peptides, hormones) require a physician-patient relationship and cannot be delegated to unlicensed staff. Nurse practitioners and PAs may prescribe under collaborative agreements per state scope-of-practice laws.
Patient intake data for medical services at a med spa is PHI under HIPAA, even if the practice also offers non-medical aesthetic services. Ensure all medical intake data is stored and transmitted in compliance with HIPAA. See HHS: https://www.hhs.gov/hipaa/index.html
Med spas should have separate consent processes for aesthetic services and medical services (weight loss medications, hormone therapy, peptides). This intake form covers the medical services side.
Want This Form Automated?
Karpa Health turns static intake forms into a fully automated clinical workflow.
- Branded patient intake embedded on your website
- AI clinical review with contraindication screening
- One-click prescribing to compounding pharmacies
- Automated follow-up and refill management
- E-signatures, HIPAA compliance, and audit trail
Related Clinical Forms
GLP-1 Patient Intake Form
Download a free GLP-1 patient intake form template for your clinic. Covers medical history, contraindications, BMI screening, and medication reconciliation. Customizable for semaglutide and tirzepatide programs.
View template →Peptide Therapy Consent Form
Free peptide therapy informed consent form template. Covers BPC-157, CJC-1295, PT-141, and other therapeutic peptides. Includes off-label use disclosures, compounding pharmacy requirements, and risk acknowledgments.
View template →Weight Loss Screening Questionnaire
Free weight loss clinic screening questionnaire template. Pre-qualify patients for GLP-1, semaglutide, and medical weight management programs. BMI calculator, comorbidity screening, and readiness assessment.
View template →Sources & References
Frequently Asked Questions
Can a med spa prescribe GLP-1 weight loss medications?
Yes, if the med spa operates under a licensed physician and the prescribing is done by a qualified provider (physician, NP, or PA with appropriate scope of practice). The med spa must maintain a proper physician-patient relationship and cannot prescribe through non-clinical staff.
Do med spas need HIPAA compliance for weight loss programs?
Yes. Any medical service that involves collecting health information, prescribing medications, or maintaining medical records requires HIPAA compliance, regardless of whether the business calls itself a 'med spa' or 'clinic.'
Should the med spa intake form be separate from aesthetic intake forms?
Yes. Medical services (prescriptions, injections for medical purposes) should have their own clinical intake and consent process separate from purely aesthetic services. This form covers the medical side; keep your aesthetic intake form for cosmetic-only services.