Patient Forms

Patient Forms 2017-08-07T09:02:39+00:00

First Name

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Last Name

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Middle Initial

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Birthdate

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Age

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Gender

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City

State

Zip

May we add your address to our internal mailing list?

YES NO

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E-Mail address

Home#

Work#

Cell#

We may call you to confirm your appt. Please use the numbers that you wish us to call.

What cosmetic procedure(s) are you interested in?

How did you hear about us?

DO YOU HAVE ANY MEDICAL ALLERGIES?
YES NO

If Yes, please explain

Please indicate any reactions to medications, drugs, tape, rubber, latex and type of reaction i.e. hives, shock, etc.

Are you on any medications or hormones?
YES NO

Please list

Do you smoke?
YES NO

Do you take any over-the-counter medications on a regular basis?
YES NO

(Aspirin, Antihistamines, etc)

NEXT

Do you have any of the following medical conditions?

Heart Disease
Lung disease
Bleeding disorders
Kidney disease
Artificial joints or heart valve
Pregnancy and/or nursing
Active skin infection
(e.g. psoriasis, eczema)
Other

Pacemaker/defibrillator
Liver disease
Hepatitis
Immune suppression
Endocrine disorders
(e.g. diabetes, PCO)
Diseases stimulated by light
(e.g. Lupus, Epilepsy, Porphyria)
Skin disorders
(e.g. keloids, abnormal wound healing)

High blood pressure
Asthma
Vein inflammation
Metal Implants
Disease stimulated by cold
(e.g. Raynaud’s)
Disease stimulated by heat
(e.g. Herpes Simplex)
Use of medications or herbs
inducing photosensitivity

Please describe your condition or any medical disorder(s) you may have, that is (are) not listed

Hormones (females only):
What would you like to improve?

 Regular period
 Going through menopause
 During pregnancy, did you experiene hyper-pigmentation or masking

Have you ever had:

 Microdermabrasion
 Chemical peel
 Non-surgical Fat Reduction

 Laser Hair Removal
 IPL/Photofacial
 CO2 Laser Treatments

 Lipo Suction
 Vein Treatments
 Facial surgery

What would you like to improve?

 Fine lines
 Frown lines
 Acne or Acne Scars
 Marionette lines
 Skin Discoloration
 Cellulite
 Sun Damage

 Large pores
 Migraines
 Crow’s Feet
 Deep Smile Lines
 Facial or Body Scars
 Stretch Marks
 Overall Skin Tone

 Excess Body Fat
 Skin Laxity
 Aging Skin
 Excessive Sweating
 Fatty Knees
 Thinning Hair
 Unwanted Hair

Last exposed to UV (sun or tanning bed):

Self-tanning lotion?
YES NO

What home skin-care products care are you now using?

NEXT

We strive to render excellent care and service to all of our patients. When an appointment is scheduled, that time has been set aside especially for you. When you cancel your appointment without ample notice to our office or if you fail to arrive, that time cannot be used to treat another patient in need.

We understand there may be times when you miss an appointment due to emergencies or obligations to work or family. We request that you please notify our office within the time frame stated below in the event that you need to reschedule your appointment. This allows other patients to be scheduled into that appointment. If a patient misses an appointment without contacting our office, this is considered a failed appointment (“No-Show, No-Call.”). If a patient accumulates a total of three (3) failed appointments, the patient will be required to prepay for any future appointments at the time of scheduling.

Additionally, if a patient is more than 15 minutes late to his/her appointment, the appointment may need to be rescheduled. If you have any questions regarding this policy, please let our staff know and we will be glad to clarify any questions you have. We appreciate your understanding

A major credit card is required to hold your reservation(s). Cancellation Periods vary depending on the length of treatment time blocked for the appointment.

TREATMENT TIMES CANCELLATION PERIOD CANCELLATION FEE
Less than 2 Hours 24 Hours $50 per Scheduled Hour
More than 2 Hours 72 Hours $50 per Scheduled Hour

The information on this form is correct to the best of my knowledge. I have read and understand the Appointment Cancellation Policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice.

I Agree

SUBMIT