testing

Item 3

PATIENT’S FULL NAME*

ADDRESS*

CITY*

STATE*

ZIP*

EMAIL ADDRESS*

Phone Number

BIRTH DATE*

AGE*

SEX*

MARITAL STATUS*

HOW DID YOU HEAR ABOUT OUR OFFICE?*

MAY WE HAVE YOUR PERMISSION TO EMAIL YOU UPCOMING PRACTICE INFO AND EVENTS?

YesNo

MAY WE CONFIRM YOUR APPOINTMENTS BY TEXT?

YesNo

OCCUPATION*

EMPLOYER *

EMERGENCY CONTACT*

PHONE*

FAMILY PHYSICIAN*

PHONE*

PLEASE CHECK IF YOU ARE INTERESTED IN RECEIVING INFORMATION ABOUT:

FillersBotox CosmeticLaser ResurfacingChemical PeelsDermaplaningSkin Tightening

MicrodermabrasionLaser Hair RemovalSpider Vein TherapyFacialsWaxingGenesis Laser

SkinCeuticalsPersonal Skin CareObagiPhoto FacialLatisse

PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE

I authorize the release of any medical and personal information necessary for my care and treatment. I authorize the release of any medical information necessary to process insurance claim(s). I authorize payment of medical benefits to the physician for service Rendered, and further understand that I am responsible for coinsurance, deductibles, and co-payment amounts as determined by my insurance carrier. Patients who carry Health Care Insurance should remember that professional services are rendered and charged to the patient and Not the Insurance Company. We will submit charges to your Insurance Company as a courtesy; however, payment of your account is your responsibility

DATE*

MEDICAL INFORMATION

NAME OF PATIENT*

REASON FOR CONSULTATION*

HEIGHT*

WEIGHT*

SERIOUS ILLNESS *(If none put none)

SERIOUS INJURIES *(If none put none)

PREVIOUS SURGERIES *(If none put none)

CURRENT MEDICATIONS *(If none put none)

PHARMACY*

PHONE*

Have You used a retinoid or accutane in the last 6 months?

YesNo

DO YOU TAKE ASPIRIN?

NoYes

DO YOU HAVE DRUG ALLERGIES?

NoYes

Hereditary Disorders*

DO YOU SMOKE?

YesNo

Do you have a history of smoking greater than 20 years?

YesNo

DO YOU DRINK?

YesNo

Is there any additional information relevant to your medical history that you feel is important?

YesNo

Please explain