Refresh Evolution

Complete Laser & Wellness Health Care

Book Appointment
  • Facebook
  • Instagram
Call Today - 778-806-4758

  • Home
  • Services
    • Overview
    • Botox
    • Laser Hair Removal
    • NanoFractional Skin Resurfacing
    • Skin Tightening
    • Fungal Nail Treatment
    • Chemical Peels
    • Microdermabrasion
    • Skin Rejuvenation
    • Venus TriBella
    • Dermal Filler
    • Dermaplaning
    • Cryotherapy
    • Viveve
    • Teeth Whitening
    • Consent Forms
  • Specials
    • All Specials
    • Port Moody Specials
    • Pitt Meadows Specials
  • About Us
    • About Refresh Evolution
    • Franchise Info
    • Before & After
    • Blog
    • Opportunities
  • Locations
    • Pitt Meadows
    • Port Moody
  • Membership
    • Pitt Meadows
    • Port Moody
  • Shop Products
  • Book Services

Medical History Form

Medical History Form

  • Date Format: MM slash DD slash YYYY
  • eg. 5'4"
  • There exists a risk if our staff is not aware of the general health and medical background of a client. This information may critically affect what procedure we may recommend or safely undertake. Please provide us with the following information and keep it updated.
  • Date Format: MM slash DD slash YYYY
  • If appropriate, I authorize the release of any medical information for the purpose of processing insurance claims on my behalf. I authorize payments of medical benefits directly to the doctor for services provided to me. A copy of this authorization shall be considered as valid as the original. I understand that photography is a necessary part of planning and evaluating cosmetic procedures. I authorize the taking of photographs at the direction of my physician or physician delegate and under such conditions as may be approved by him/her. These photographs will be used solely for documentation purposes and will be kept confidential unless otherwise disclosed.

    I understand that there is a consultation fee for the initial visit which is due at the time of my appointment unless other arrangements have been made in advance.

  • Date Format: MM slash DD slash YYYY

Launch Event

October 23rd 7-9pm

  • This field is for validation purposes and should be left unchanged.
Refresh Evolution Click Here to Book Your Complimentary Consultation
Refresh Evolution
Book Appointment Locations
Accessibility Statement

Pitt Meadows Location

Refresh Evolution - Pitt Meadows
#105-10996 Barnston View Road.
Pitt Meadows BC V3Y 0B9
Phone: 778-806-4758

Port Moody Location

Refresh Evolution - Port Moody
86 Kyle Street
Port Moody BC V3H 1Z3
Phone: 778-806-4758

Follow Us

  • Facebook
  • Instagram
© 2021 Full Frame Marketing Inc | Site Map | TOS/Privacy Policy | Refresh Evolution
Choose A Location

Pitt Meadows

Port Moody

Booking

TESTING