Aesthetic Patient Paperwork

Patient:

Date of Birth:

Today's date:

MEDICAL HISTORY

Have you been previously diagnosed with any of the following:

Cancer

YES NO

DESCRIPTION

Seizures

YES NO

DESCRIPTION

Thyroid Problems

YES NO

DESCRIPTION

Fever Billisters/Cold Sores

YES NO

DESCRIPTION

Fever Billisters/Cold Sores

YES NO

DESCRIPTION

Heart Problems

YES NO

DESCRIPTION

Hepatitis or Liver Problems

YES NO

DESCRIPTION

HIV

YES NO

DESCRIPTION

Diabetes

YES NO

DESCRIPTION

Hormonal Imbalance

YES NO

DESCRIPTION

Keloid or Hyperthrophic Disorder

YES NO

DESCRIPTION

Autoimmune/Neuromuscular disorder

YES NO

DESCRIPTION

Other

Have you ever had any surgery?

YES NO

If yes, epecify:

Are you pregnant?

YES NO

Nursing?

YES NO

Do you wear sunscreen?

YES NO SOMETIMES

Do you bleed easily?

YES NO

List all medications you are currently taking including prescriptions, over-the-counter medications, antibiotics, vitamins, and herbals supplements:

Are you allergic to any medications?

YES NO

If yes, list:

Have you ever had dental anesthesia or local anesthetics?

YES NO

Bad reaction?

YES NO

Do you drink alcohol?

YES NO

If yes, drinks per day:

Do you use IV drugs?

YES NO

If yes, what?

How often?

Do you smoke?

YES NO

If yes, how much:

SKIN CARE

What products do you use on your face at home?

Is your skin

NORMAL

OILY

DRY

COMBINATION

Do you have any specificconcerns about your skin?

PREVIOUS INJECTIONS & LASER TREATMENTS

Botox/Xeomin/Dysport

YES NO

Add new row

Juverderm Products

YES NO

Add new row

Restylane/Radiesse Products

YES NO

Add new row

Sculptra

YES NO

Add new row

Laser Treatments (IPL, Vbeam, CO2, Tightening)

YES NO

Add new row

Body Contouring (CoolSculpting/SculpSure)

YES NO

Add new row

How did you hear about us?

Referral

Social media

Radion

Internet

Newspaper

Event

Other

What is your occupation?

Completed By:

Patient

Signed by Patient:

Date:

Initial

Nurse

Review By:

Date:

Initial

PATIENT INFORMATION

New Patient

Name Change

Address Change

Insurance Change

THIS SECTION MUST BE COMPLETED FOR ALL PATIENTS:

Today's Date:

Last Name:

First Name:

MI:

Date of Birth:

Age:

Sex:

Male Female

SS#:

ADDRESS:

Mailing Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Cell Phone:

Email address

PARENT, SPOUSE, OR RESPONSIBLE PARTY (If different from patient)

Last Name:

First Name:

M.I.:

Date of Birth:

INSURANCE COVERAGE

Insurance Co. Name:

Name of Policy Holder (Insured):

Policy Holder (Insured) Date of Birth:

EMERGENCY CONTACT INFORMATION

In case of Emergency, who should be notified?

Phone:

Relationship to patient:

Do you give our office permission to discuss your medical information with family member?

YES NO

If yes, please provide their names and phone numbers below

Add Name

May we leave personal medical information on your answering machine or cell phone?

YES NO

May we e-mail personal medical information to you?

YES NO

Preferred Pharmacy for prescriptions:

RECEIPTS OF NOTICE OF PRIVACY PRACTICES:

My signature below indicates that I have received and/or reviewed a copy of my physician's Notice of Uses and Disclosures of Protected Medical Information (Notice of Privacy Practices). I have been given the option of signing a separate Patient Consent Form.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient or Responsible Party Signature

Date:

PAYMENT POLICY:

You will be responsible for paying your annual deductible, copayment and charges for any non-covered medical and cosmetic services at the time of service.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Responsibility of Payment Signature

Date:

Your information will be encrypted.