New Patient Paperwork (Skin by Design Spa)

Full Name:

Date of Birth:

Reason for visit:

What is your occupation?

Pharmacy location and phone number:

Any prior tanning bed use?

yes

Blistering Sunburns?

yes

Do you wear sunscreen when outdoors?

yes

If yes, what SPF?

Are you allergic to any medications?

yes

If yes, list:

Have you ever had a reaction to dental or local anesthesia?

yes

If yes, describe reaction:

Do you take antibiotics before you go to the dentist?

yes

If yes, why?

Do you have a pacemaker or implanted defibrillator?

yes

If female, are you pregnant?

yes

Nursing?

yes

Do you smoke?

yes

If yes, how much?

Do you drink alcohol?

yes

If yes, how much?

List all medications that you regularly take, as well as their dosages and frequencies: (including prescriptions, over the counter medications, vitamins and herbal supplements)

MEDICAL HISTORY

Past medical history:

Past surgical history?

Patient Contact Information

Name

Age

Address

Date of Birth:

Gender

Male

Female

Marital Status:

Married

Single

Widowed

Primary Language

English

Spanish

Other

Home Phone:

Mobile:

Work:

Race:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other pacific

White

Other

Ethnicity:

Not Hispanic or Latino

Hispanic or Latino

Primary Care Doctor & Address

Email address

Preferred Contact

Home Mobile Work Email

Insurance policy holder information / responsible party complete:

Name:

Relationship to patient:

Employer:

Address:

Contact number:

DOB:

Gender

Male Female

Emergency Contact:

Name:

Relationship:

Contact Number:

As a patient of our practice, from time to time we may need to communicate with you. To preserve your privacy, please indicate your preferred method for us to communicate medical information to you and others involved in your care.

Examples of medical information include test results, appointment reminders, and other information of a clinical nature.

Without specific permission, we will not release your medical information.

Please identify those individuals to whom we may release your medical information.

Name:

Relationship:

Phone Number:

Name:

Relationship:

Phone Number:

Do NOT leave any medical information on machine or voicemail.

I give permission to Lawlor Dermatology to notify me of test results, appointment reminders and other information regarding my health information as follows:

Preferences

Message on answering machine

Message on work voicemail

Message/text on cell phone

I understand that by entering my telephone number, I agree to receive mobile messages.

I assume responsibility to inform the practice of changes in my telephone numbers and my preferences

I agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

Electronic Signature*

Date

Patient HIPAA Consent Form

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to conduct:

Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
Obtaining payment from third party payers (e.g. my insurance company);
The day-to-day health care operations of your practice.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that your practice maintains the most up to date version of its Notice of Privacy Practices. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoked this consent is not affected.

Electronic Signature

Date

Patient Financial Responsibility Agreement

Thank you for choosing Skin By Design for your cosmetic needs. It is our pleasure to offer you the latest cutting edge services and medical grade products to meet your skin care needs. Please take a moment to familiarize yourself with our policies.

Payment:

This account is self-pay and payment is required in full at the time of each service. We accept the following forms of payment: Cash, Checks (with valid ID; no out of state), Visa, MasterCard, Discover. Financing options are available through CareCredit and Cherry. There is a returned check charge of $30.

Gift Cards and Packages:

Gift cards are available and may be redeemed for specific cosmetic services and packages. Packages offer our clients significant savings. Services purchased as a package are not transferable. If you are unable to use your full package, a credit may be issued at the discretion of the Provider. Refunds will not be provided. Credits are not transferable. Packages must be redeemed within 1 year of purchase.

Promotions:

Special promotions may not be combined with any other discounts.

Cancellation Policy:

Skin By Design reserves the right to charge a fee for the following:

Appointments canceled 24 hours or less of scheduled appointment
No show appointments

Outstanding fees must be paid in full prior to rescheduling a missed appointment.

Arriving late will deprive you of valuable treatment time. We will make every effort to perform your entire treatment in the remaining scheduled time, but reserve the right to reschedule your appointment if you arrive more than 10 minutes late and charge the fee listed above.

I clearly understand and agree that all services rendered to me may be charged directly to me, and that I am personally responsible for full payment. I understand that even if I suspend or terminate treatment, any fees for professional services rendered to me or to my dependent up to the point of termination will be immediately due and payable.

I acknowledge that I am responsible for any outstanding fees for services provided to me by Skin By Design.

Any other arrangements that may involve payment plan or payment deferral must be made in writing with the office manager or business manager of the Practice. Verbal agreements are not acceptable.

I acknowledge that Skin By Design reserves the right to charge 50% of the desired service if I cancel the scheduled appointment 24 hours or less on the day prior to my appointment. I acknowledge that Skin By Design reserves the right to charge 100% of the desired service if I do not attend or cancel the scheduled appointment on the day of the scheduled appointment. I further acknowledge that Skin By Design reserves the right to reschedule my appointment if I am more than 15 minutes late to the scheduled appointment.

Electronic Signature

Date

Your information will be encrypted.