Health Intake Form | MajesticGlow.Health

Majestic Glow Health & Aesthetics

305 3rd St SE Suite 350, Cedar Rapids, IA 52401

New Patient Medical History

Please complete this form before your first appointment. All information is kept strictly confidential and protected under HIPAA.

Patient Identity

Personal Information

Date of Birth*

Home Address*

City, State, ZIP*

Phone Number*

Emergency Contact Name*

Emergency Contact Phone*

Relationship to Emergency Contact*

Primary Care Physician

Primary Care Physician Name

PCP Clinic / Practice

PCP Phone Number

Primary Insurance

Insurance Carrier / Payer Name (e.g. Blue Cross Blue Shield)*

Electronic Payer ID (if known)

Member ID / Policy Number*

Group Number

Plan Type

Subscriber Name (if different from patient)

Subscriber Date of Birth (if different)

Patient's Relationship to Subscriber

Coverage Effective Date (if known)

Insurance Customer Service Phone (back of card)

Insurance Card Photos

Attach photos of the front and back of your insurance card so our staff can verify your eligibility before your appointment.

Card — Front

Tap to upload photo

Card — Back

Tap to upload photo

Insurance eligibility verification: Not Yet Verified — our staff will confirm your coverage before your visit.

Secondary Insurance (if applicable)

Secondary Insurance Carrier

Secondary Member ID

Secondary Group Number

Secondary Subscriber Name (if different)

Patient's Relationship to Secondary Subscriber

Medical History

Chronic Medical Conditions / Diagnoses (list all, or write 'None')*

Past Surgeries or Hospitalizations (include year if known)*

Current Medications (name, dose, frequency — or write 'None')*

Known Allergies (medications, foods, environmental — or write 'None')*

Blood Type (if known)

Review of Systems

Cardiovascular (chest pain, palpitations, hypertension, etc.)

Respiratory (shortness of breath, asthma, COPD, etc.)

Gastrointestinal (nausea, reflux, bowel changes, etc.)

Musculoskeletal (joint pain, arthritis, injuries, etc.)

Neurological (headaches, dizziness, seizures, etc.)

Endocrine (diabetes, thyroid disease, etc.)

Mental Health (depression, anxiety, etc. — optional)

Skin / Dermatology (rashes, eczema, psoriasis, etc.)

Any other symptoms or concerns not listed above

Social History

Tobacco / Nicotine Use*

Alcohol Use*

Recreational Drug Use (current or past)*

Exercise Frequency

Occupation

Family History

Significant Family Medical History (heart disease, diabetes, cancer, etc. — or write 'None known')*

Reason for Visit & Goals

Primary Reason for Seeking Care (your main concern or symptom)*

Health Goals (what would you like to achieve through this care?)*

Previous Treatments for This Concern (if any)

How did you hear about Majestic Health?

HIPAA Privacy Notice

Electronic Signature — Legally Binding

By typing your full legal name below, you certify that all information provided is accurate and complete to the best of your knowledge, and that you are executing this form as a legally binding electronic signature pursuant to the E-SIGN Act and UETA.

Draw Your Signature *

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Patient—

Timestamp (UTC)Oct 16, 2026, 9:57:53 AM UTC