📞 (301) 201-3479
New Patients · Secure Form

Patient Intake & Consent

Dr. Itamar Simhon · Montgomery County, MD — please complete this before your appointment. It takes about 5 minutes, and everything you enter is private and HIPAA-protected.

🔒 HIPAA protected ⏱ ~5 minutes ✅ Required before your first visit

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Form received

Thank you — Dr. Simhon has received your intake form and will review it before your appointment.
Questions? Call us at (301) 201-3479.

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Patient Information
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Medical History
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Medications & Allergies
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Previous Treatment History
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Lifestyle
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Informed Consents

General Treatment Consent

I voluntarily consent to evaluation and treatment by Dr. Itamar Simhon. I understand that concierge services are provided at my chosen location and that I may ask questions at any time before, during, or after treatment. I acknowledge that results are not guaranteed and individual outcomes vary.

IV Hydration & Vitamin Therapy

I understand that IV therapy involves insertion of an intravenous catheter and infusion of fluids, vitamins, minerals, and/or medications directly into my bloodstream. Potential risks include: bruising, infection, vein irritation, air embolism, allergic reaction, electrolyte imbalance, and rare systemic reactions. I confirm all medical history and medication information I have provided is accurate and complete.

Aesthetic Injectables — Neurotoxins & Fillers

I understand that neurotoxin injections (Botox, Dysport, Xeomin, Jeuveau, Daxxify, Letybo) and dermal fillers (Juvederm, Restylane, Radiesse, Sculptra, Belotero) are medical procedures with potential risks including: bruising, swelling, asymmetry, infection, migration, vascular occlusion, tissue necrosis, vision changes, and allergic reactions. These treatments are temporary and touch-ups may be needed. I am NOT currently pregnant or breastfeeding (or have disclosed this to Dr. Simhon). I have not taken blood thinners within 5 days unless medically required.

Photography Authorization

HIPAA Privacy Notice: Your health information is protected under HIPAA. It will never be sold or shared without your written authorization, except as required by law. All submissions are transmitted securely and stored only by Dr. Simhon's practice.
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Certification & Signature

I certify that all information provided is true, accurate, and complete to the best of my knowledge. I have read and understood all consents above and agree to the terms of treatment. I am 18 years of age or older, or the legal guardian of the patient named on this form.

Acts as your electronic signature
🔒 Securely submitted · HIPAA protected · Goes directly to Dr. Simhon