Stush Medical Form
Your information
Name
*
Name
First
First
Last
Last
Date of Birth
*
Phone Number
*
Email Address
*
Desired Services
Check the symptoms that you' re currently experiencing:
Botox Cosmetic
Xeomin
Dysport
Juvederm
Restylane* (Silk, Defyne & Refyne)
Radieese
Belofero
Intravenous (IV) Fluid Vitamin Infusion
Intramuscular (IM) Shots
Trizepatide (Mounjaro)
Semaglutide (Ozempic)
MICC
MICC
Fat Dissolving Injections
Testosterone Treatment
Comprehensive Medication Review
Annual Physical
Medical Clearance
STD/STI Testing
Are you currently taking any medications?
*
No
Yes
Yes
Do you have any known medical allergies?
*
No
Yes
Yes
Are you currently under medical treatment?
*
No
Yes
Yes
Have you been admitted to hospital or had surgery within the last 2 years?
*
No
Yes
Is there any additional information you would like us to know?
Submit
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