Name. Address. City State Zip. Home Phone . Cell Phone Can we contact you by text message? Today s Date Date of Birth.
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1 Name Address City State Zip Home Phone Cell Phone Can we contact you by text message? Today s Date Date of Birth Referred by We re Social! on ; themedspa on ; themedsparpsc on Let us follow you too: Are you a patient at Raleigh Plastic Surgery Center? Yes No If so, who is your physician? 1. Have you ever been diagnosed with any of the following skin disorders? Check all that apply Acne Seborrhea Psoriasis Skin Cancers Mycosis(fungal infection) Contact Dermatitis Have you ever been diagnosed with any of the following? Check all that apply Anxiety Depression Cancer Hemophillia Diabetes Hepatitis Migraines Thyroid Herpes Asthma Epilipsy HIV Sinus Problems Heart Problems High or Low Blood Pressure Other: 2. Do you suffer from any allergies? **Important** Cosmetic ingredients, food, iodine, sulfer, medications, hay fever, latex: Yes No If yes, please specify 1
2 3. Are you currently undergoing chemotherapy or radiation therapy? NO YES (please specify) 4. Are you currently taking any medications, herbs, vitamins? Internal: External: 5. Have you ever been prescribed Accutane? NO YES If yes, last date used? 6. Do you have any body implants? NO YES If so, please specify 7. Do any of the following apply to you? Smoke Exercise Eat Spicy Foods Wear Contact Lenses 8. When exposed to the sun, do you? Burn Easily Tan Easily Burn Then Tan Fever Blisters 9. How often do you consume alcohol? Regularly Seldom Never 10. How many glasses of water do you consume daily? For Women Only... Check all that apply Regular Menstruation Pregnant Hormonal Problems Menopause IUD (copper or plastic) Lactating Birth Control Pill Hemophilia Hepatitis Herpes HIV Other **For an effective treatment, please be as accurate as possible 2
3 Skin Type Normal Dry Sensitive Combination Oily Sensitive/Breakout Very Sensitive/Rosacea Acne Mature What are your present skincare concerns? Check all that apply Crows Feet/Wrinkles Puffiness Lack of Elasticity Dark Shadows Hyper pigmentation Whiteheads Ingrown Hairs Enlarged Pores Papules or Pustules (inflamed) Blackheads Severe Sun Damage Have you ever received any of the following medical or surgical procedures? Rhytidectomy (Face lift) Rhinoplasty (Nose) Blepharoplasty (Eye lift) Laser Resurfacing Dermabrasion Medical Acid Peels Collagen Injections Restylane Injections Botox Injections Other What is your current skincare regimen? Cleanser Toner Moisturizer Exfoliator Mask Make-up Sunscreen Brand(s) If you could improve one thing about your skin, what would it be? Thank you for choosing The MedSpa at Raleigh Plastic Surgery Center as your skin care specialist. Your treatment options and consent will be discussed during your complimentary consultation and possible treatment(s) today. 3
4 Consent for Treatment I hereby consent to and authorize The MedSpa to perform the following procedure(s): chemical peels, dermaplane, micro-needling, facials, waxing, make-up application, extractions, all aesthetic services, product recommendations, and any other procedures recommended. The nature and the purpose of the treatment(s) have been explained to me, along with the risks and hazards involved by The MedSpa, and I have voluntarily elected to undergo the treatment/procedure(s). I also recognize there are no guaranteed results and that individual results are dependent upon age, skin condition, and lifestyle. I am aware that there is the possibility I may require further treatments to the treated areas to obtain the expected results at an additional cost which have been explained to me. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult The MedSpa immediately. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I have read and fully understand this agreement and all information detailed above. I understand the procedure(s) and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the aesthetician or The MedSpa, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this skin care procedure which may be affected by the treatment performed today or any future treatments. The MedSpa at Raleigh Plastic Surgery Center Policies (please initial) A 24-hour cancellation notification is required to avoid a cancellation fee of $25. No refunds and/or exchanges on retail products (please initial) For safety reasons, children are not allowed in the treatment room or left unattended in The MedSpa at Raleigh Plastic Surgery Center. Client Name(signature) Date / / The MedSpa (witness) Date: / / 4
5 Smoking Risk Consent The MedSpa in conjunction with Raleigh Plastic Surgery Center stands by their commitment in providing information, products, and services to achieve the best possible cosmetic outcome. The MedSpa recommends smokers abstain from nicotine or nicotine substitutes for a minimum of 6 weeks before and after in office procedures and treatments. Carcinogens from smoke and secondhand smoke may impact your treatment and desired end result. There is greater risk in smokers for bad scarring, hemotoma formation, intraoperative bleeding, bleeding, poor or delayed healing, hair loss, sloughing of the skin (skin loss), infection, increased or prolonged bruising and hyperpigmentation. I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT TO HAVE PROCEDURES AND TREATMENTS PERFORMED. I UNDERSTAND THE POTENTIAL RISKS INVOLVED AND THE POSSIBLE IMPACT CONTINUED SMOKING HAS ON MY DESIRED COSMETIC RESULT AND WISH TO PROCEED WITH TREATMENT. Patient Signature) Date / / Witness Date: / / 5
6 Medical Records Release Medical Records Release Date: Patient Signature: Print Patient Name: Date of Birth: ** To protect your privacy in accordance with HIPAA standards, photo id must accompany your request for release of your medical records. If you are faxing this form to our office, please include a faxed copy of a photo id that also contains your signature (ie: driver s license). If you are presenting this form in person, please be prepared to present photo id which also contains your signature.** By signing this document, you agree to the exchange of records between: Raleigh Plastic Surgery Center & The MedSpa at Raleigh Plastic Surgery Center.
MEDICAL SKINCARE ASSESSMENT
MEDICAL SKINCARE ASSESSMENT Patient Name Date Address (City) (State) (Zip) Phone (Home) (Cell) (Work) Date of Birth Who Referred You? Email Address: Emergency Contact Phone PERSONAL HISTORY Do you wear
Last Name: First Name: DOB: / / Cell Phone # ( ) Address: City: State: Zip: How did you hear about us?
Personal Information Last Name: First Name: DOB: / / Cell Phone # ( ) Address: City: State: Zip: Email: How did you hear about us? Personal History Have you ever seen a physician or technician specifically
Date: Name: Age: DOB: Address: City: Zip: Home Phone: Mobile Phone: If you are not able to take a call is it ok to leave a message and with whom?
Patient Intake Form Date: Name: Age: DOB: Address: City: Zip: Home Phone: Mobile Phone: If you are not able to take a call is it ok to leave a message and with whom? Work Phone: Occupation: E-mail: Referred
Name: Date: DOB: Phone: Service: Notes:
Name: Date: DOB: Phone: Email: Service: Notes: ` TODAY S DATE REFERAL NAME/LAST FIRST M F DOB (OPTIONAL) ADDRESS CITY STATE ZIP PHONES/HOME WORK CELL EMAIL ADDRESS FAX NUMBER HEIGHT FT IN WEIGHT OCCUPATION
Patient Information. First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( )
Today's : Patient Information First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( ) Email: Work Phone: ( ) Primary Care Physican: Cell Phone: (
INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY
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F M S M W D. Age Birth Date Gender Marital Status Cell Phone
MIDWEST DERMATOLOGY CLINIC, PC Patient Legal Name Last First Middle Initial Today s Date Mailing Address Street City and State Zip Home Telephone F M S M W D. Age Birth Date Gender Marital Status Cell
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Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy
Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy Patient Number: Date of First Visit: Last Name: First Name: MI: Address: City: State: Zip Code: Email address: Phone: H
MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED
MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED Patient Information Name: DOB: / / Gender: M F Home Address: Home Phone: City, State, Zip: Work Phone: Email Address: Cell Phone: I do not want
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM B S M R W A G KS MAC Z GR SO ZA L Please tell us about yourself so we can help you make the best decisions about your care. Date: Social Security #: E-mail: Name: MR / MRS / MS
arah s CLIENT INFORMATION M A S S A G E T H E R A P Y
1 arah s M A S S A G E T H E R A P Y CLIENT INFORMATION Please take care to fill out this form thoroughly and carefully. The information will help your massage therapist provide optimal care. Your cooperation
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
Patient Information. Spouse or Responsible Party Information. Insurance Information
Patient Information Full Name Preferred Name Home Address City, St, Zip Home Phone # E-Mail Address Employed By Work Phone # Occupation Pager/Cell Phone # Male Female Birth Social Security # Married Single
Information and Consent Form for SmartXide DOT Treatment PROCEDURE
Information and Consent Form for SmartXide DOT Treatment This consent form includes general descriptions of various dermatological laser treatments, including possible benefits and risks that may occur
GETTING STARTED INTRODUCTORY FORM
GETTING STARTED INTRODUCTORY FORM I am interested in: In office consultation Questions regarding my appointment: Phone consultation Skype consultation I am interested in the: Getting Started Program Getting
Child Health/Dental History Form
Child Health/Dental History Form Patient s Name Nickname Date of Birth LAST FIRST INITIAL Parent s/guardian s Name Relationship to Patient Address PO OR MAILING ADDRESS CITY STATE ZIP CODE Phone Sex M
AHI - New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT We are concerned with your privacy rights. We are complying with national guidelines (HIPAA) to safeguard your personal health information. We keep a record