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1 Thomas Theocharides, MD, FACOG, FRCS(C), FSOGC Dr. Theocharides received his undergraduate training at the prestigious McGill University in Montreal, Quebec and acquired his medical degree at the University of Sherbrooke in 1980 where he became fluent in French. Dr. Theocharides is internationally trained, with his expertise spanning both coasts of Canada where he was appointed a Fellow of the Royal College of Surgeons of Canada. Dr. Theocharides (pronounced Thee o ka ri dis, but better known simply as Dr. T) is at the cutting edge of some of the latest research being one of a handful of doctors investigating non---invasive skin tightening for many body areas, including vaginal. He was the first to introduce SmartLipo to Monmouth County and has trained other doctors in advanced techniques for both BOTOX Cosmetic and fillers. He was instrumental in setting up an entire facility to perform laser liposuction under local anesthesia in another state. His great interest and passion for aesthetics stems from his unsurpassed dexterity in cosmetic procedures as well as his meticulous nature and artistic eye for beauty and symmetry. He received his aesthetic training from several of the most renowned plastic surgeons and dermatologists including the inventor of the FotoFacial procedure. His precise techniques result in beautiful aesthetic enhancements that meet each of his patients individual needs. Dr. T. realizes that inward and outward beauty are connected. He always has an encouraging word for his patients and while he is open to pray with those that ask, it is never imposed. B I O G R A P H Y P O S T D O C T O R A L T R A I N I N G Specialized training in aesthetics with 15 years of experience including BOTOX, XEOMIN, the Liquid Facelift (also known as Facial Volume Restoration), Fillers including VOLUMA, Bellafill and Fat Transfer, treatment of wrinkles & sun damage with fractional CO2 resurfacing, acne scars with Dermapen Micro---needling, the one hour Silhouette Lift facelift, FotoFacial (IPL/BBL), skin tightening with ThermiRF, ThermiRase brow lift, blepharoplasty, jowl and neck lift without surgery, excessive sweating (hyperhidrosis), laser hair removal, sclerotherapy, laser liposuction, vaginal rejuvenation including hymenoplasty, labiaplasty, and vaginal tightening. In addition, anti---aging treatments with bio---identical hormones can help restore your hormone balance for a younger you. E D U C ATI O N Faculty of Engineering, McGill University, Montreal, Quebec, Canada with scholarship. Received Diploma of Collegial Studies in Faculty of Science, McGill University, Montreal, Quebec, Canada. Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC, Canada. Received M.D. degree in Internship at Rush Presbyterian St---Luke s Medical Center, Chicago, IL. Specialty training in Ob/Gyn at the University of British Columbia, BC, Canada where he received his Board Certification. L I C E N S U R E A N D B O A R D C E R T I F I C A T I O N Licensed in the state of New Jersey since 1996, previously Utah and Indiana Board Certification in Obstetrics and Gynecology since 1985 H O S P I T A L A FFI L I A T I O N S Monmouth Medical Center, Long Branch, NJ Robert Wood Johnson University Hospital, Hamilton, NJ Raritan Bay Medical Center both Old Bridge and Perth Amboy Divisions M E M B E R S H I P S AND F ELLO W S H I P S Member Society of Cosmetogynecologists (ISCGYN) Member American Academy of Cosmetic Surgeons (AACS) Member American Academy of Anti---Aging Medicine (A4M) Fellow of the Royal College of Surgeons of Canada (FRCS(C)) Fellow of the Society of Obstetricians and Gynecologists of Canada (FSOGC) Fellow of the American Congress of Obstetricians and Gynecologists (FACOG) Member American Society for Laser Medicine and Surgery, Inc (ASLMS) and Lipo---Suction Surgery
2 DEMOG R APH ICS 804 W. Park Ave, Ocean, NJ EZ.BEAUTY Personal Information How do you prefer to be addressed: Name: Birth date: - - LAST FIRST MI MAIDEN/PREVIOUS Age: Current Status: M / S / D / W / Address: City/State: Zip: Home: ( ) - Mobile: ( ) - E mail: Alt Employer: Phone: ( ) - Contact in case of Emergency: Phone: ( ) - SSN: - - Driver's Lic#: Contact Information Best way to be reached: Mobile Home Work E Mail Letter CIRCLE ALL THAT APPLY Best day and time to call for reminders/follow-up: If you are not in, with whom may we leave a message? No one / How may we confirm appointments / follow-up? (circle all that apply / cross out what must not be used) Call: Mobile / Home / Work Voice mail Text Message Letter Postcard How do you want to learn about specials, Open Houses, promotions, or the latest in aesthetics/wellness? No thank you / Voice mail Text Message Letter Postcard / Call: Mobile / Home / Work How did you find us? Referral Source: IF THE INTERNET, PLEASE LIST SITE AND/OR SEARCH WORDS If someone recommended you, may we thank them? (Circle one) YES NO (I prefer to remain anonymous) Client Signature: Date: Let Beginnings Bring Out The Best In You! Ministering the Love of God Through Beauty Thomas Theocharides, MD / rev:
3 IN TE R E STS 804 West Park Ave, Ocean, NJ EZ.BEAUTY wwwbeginningsaal.com NAME: DOB: DATE: Circle your areas of interest, services you desire, or simply detail your interests below: Silhouette Lift Bellafill BELOTERO Juvederm Radiesse Restylane Sculptra VOLUMA Liquid Facelift ThermiTight ThermiSmooth ThermiRase ThermiDry ThermiVa Thermi250 Kybella Turkey Neck BOTOX XEOMIN Wrinkles around the Mouth / Eyes Sagging Brow / Chin / Neck Sun Damage Rosacea Broken Capillaries Acne Scars Enlarged Pores Brown Spots Red Spots Fine lines & Wrinkles Uneven Texture Fractional Laser Resurfacing (Fraxel /Thermage ) Skin Tightening PhotoRejuvenation (IPL) DCL Medical Skin Care Dark Circles Spider Veins Facial Veins Sclerotherapy Dermapen Micro-needling Hyperhidrosis (excessive sweating) Laser Hair Removal Permanent Cosmetics Cellulite Body Sculpting Stubborn Fat Laser Lipo Fat Transfer Urinary leakage Vaginal Dryness Vaginal Rejuvenation Labiaplasty Hymen Restoration G/O-Spot Enhancement Excessive or Uneven Labia My specific concerns: 1. Have you ever had a laser procedure? No Yes 2. Ever had skin resurfacing/chemical peels? No Yes 3. History of cold sore/herpes/recurrent skin infection? No Yes 4. History of neurologic disease or muscle weakness? No Yes 5. History of poor or slow healing/keloid scars? No Yes 6. History of bruising or bleeding disorder? No Yes 7. History of skin cancer or suspicious moles? No Yes 8. Taking gingko, vitamins or any other supplements? No Yes 9. Taking prescription medications/alcohol regularly? No Yes 10. Any allergies to medications/latex/sulfites? No Yes 11. Taken Accutane (isotretinoin)? No Yes 12. Using Retin-A or alpha/beta hydroxyl acids? No Yes Health History (Please circle or complete) FOR WOMEN ONLY (N/A = not applicable): 13. When was your last period 14. Was it normal? N/A No Yes 15. Are you pregnant/trying to get pregnant? N/A No Yes 16. Using anything to prevent pregnancy? N/A No Yes 17. Melasma (mask of pregnancy)? N/A No Yes 18. Change in skin color with pregnancy? N/A No Yes 19. Urinary leakage / bladder control? No Yes 20. Concerned about vaginal dryness? No Yes 21. Vaginal looseness / vaginal rejuvenation? No Yes 22. Difficulty reaching orgasms? No Yes I have answered all questions truthfully to the best of my ability. I have had the opportunity to ask about any question that was unclear and have this explained to me to my satisfaction. I will not hold anyone responsible for any adverse reaction that I may have as a result of any false information or information I have not disclosed. Client Signature: Date: Let Beginnings Bring Out The Best In You! Ministering the Love of God Through Beauty Thomas Theocharides, MD / rev:
4 HE AL T H QUEST IONS 804 West Park Ave, Ocean, NJ EZ.BEAUTY NAME: DOB: AGE: PERSONAL PAST HISTORY (circle one for each number: N = no, Y = yes,? = not sure) 1. Asthma N Y? 2. Angina N Y? 3. Heart attack/murmur N Y? 4. Mitral valve prolapse N Y? 5. High blood pressure/stroke N Y? 6. Blood clots (legs or lungs) N Y? 7. Diabetes N Y? 8. Lupus/Collagen Vascular dis N Y? 9. Cancer N Y? 10. Thyroid disease/goiter N Y? 11. Anemia N Y? 12. Blood transfusion N Y? 13. Reflux/hiatal hernia/ulcers N Y? 14. Hepatitis/Jaundice N Y? 15. Alcoholism N Y? 16. Drug dependency/abuse N Y? 17. Nervous breakdown N Y? 18. Other past problem not listed N Y? CURRENT MEDICATIONS, VITAMINS, & SUPPLEMENTS if none check here: (include ALL vitamins, herbs, hormones and nonprescription medications taken regularly) Drug Name Dosage How long Doctor Drug Name Dosage How long Doctor (1) (5) (2) (6) (3) (7) (4) (8) SURGERIES/HOSPITALIZATIONS/INJURIES/ILLNESSES if none check here: REASON/TYPE OF INJURY/HOSPITAL DATE REASON/TYPE OF INJURY/HOSPITAL DATE SOCIAL HISTORY HEALTH HABITS 1. Do you smoke? no yes 2. Drink any alcohol daily? no yes 3. Recreational drug use? no yes SYSTEM REVIEW: N = never had, P = previous problem, C = current problem 1. CONSTITUTIONAL a. Weakness or fatigue N P C b. Lightheadedness N P C c. Frequent bruising N P C 2. CARDIOVASCULAR a. Chest pain/pressure N P C b. Shortness of breath N P C c. Palpitations N P C d. Swelling of legs N P C 3. RESPIRATORY a. Chronic cough N P C b. Bloody phlegm N P C c. Wheezing/Congestion N P C 4. NEUROLOGIC a. Tremors or Seizures N P C b. Numbness N P C c. Difficulty walking N P C d. MS / ALS / weakness N P C 5. MENTAL/EMOTIONAL a. Depression N P C b. Frequent crying spells N P C c. Problematic anxiety N P C 6. ALLERGIES: Drug N P C Latex N P C Environmental N P C Other I have answered all questions truthfully to the best of my ability realizing that failure to disclose health information may increase my risks and/or result in complications. I will not hold anyone responsible for any adverse reaction resulting from any information I have not disclosed. DATE TODAY SIGNATURE: Thomas Theocharides, MD / rev:
5 BEGINNINGS AESTHETIC & WELLNESS LLC 804 WEST PARK AVE, OCEAN, NJ RT 9 NORTH, HOWELL, NJ PHONE: FAX: THOMAS THEOCHARIDES M.D., F.A.C.O.G. PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION With my consent, Beginnings Aesthetic & Wellness LLC may use and disclose protected health Information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Beginnings Aesthetic & Wellness LLC Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. Beginnings Aesthetic & Wellness LLC reserve the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Privacy Officer, Beginnings Aesthetic & Wellness LLC, at 804 West Park Avenue, Ocean, NJ With my consent, Beginnings Aesthetic & Wellness LLC may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. With my consent, Beginnings Aesthetic & Wellness LLC may send an or mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. I have the right to request that Beginnings Aesthetic & Wellness LLC restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Beginnings Aesthetic & Wellness LLC use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Beginnings Aesthetic & Wellness LLC may decline to provide treatment to me. Print Name of Patient or Legal Guardian Signature of Patient or Legal Guardian Patient s Name Date I ACKNOWLEDGE THAT I HAVE RECEIVED BEGINNINGS AESTHETIC & WELLNESS LLC UNOTICE OF PRIVACY PRACTICESU POLICY (OR IT HAS BEEN MADE AVAILABLE TO ME) Patient s Name Date Rev:
6 Be g i n n i n g s A e s t h e t i c & Wellness LLC Thank you for choosing Beginnings Aesthetic & Wellness as your aesthetic care specialist. We consider it a privilege that you have chosen us for your aesthetic rejuvenation goals. Please read the below policies carefully. Cancellation Policy We value your time and trust you value ours. To minimize no show appointments and to utilize cancelled appointments for other patients, we ask that you please provide the office 24---hour advance notice if you are unable to keep your appointment. Even if it is after hours, call 877.9EZ.BEAUTY. If no reply call the answering service at There will be a $50.00 charge for missed appointments. An appointment is considered missed if 24---hour notice is not given or if you are more than 30 minutes late for your appointment. Financial Policy We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. We strive to inform you of all the medical aspects of your needs as well as advise you on our payment policies for all cosmetic services. It is important that you understand that all services once rendered are non---refundable. Although many follow ---up visits are complementary, additional services most likely will incur additional costs. This may relate to wanting additional BOTOX or fillers at that visit, for example, or if surgical revisions are necessary. The following is a statement of our Financial Policy. Please read and sign prior to treatment. FULL PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED AND MAY BE REQUESTED JUST PRIOR TO RECEIVING YOUR TREATMENT. THIS WILL ALLOW YOU AND THE DOCTOR TO FOCUS ON YOUR SERVICE AND HAVE THE CONVENIENCE OF LEAVING THE OFFICE WITHOUT WAITING. TO BETTER SERVE YOU, WE ACCEPT CASH, CHECKS, CARE CREDIT, AND MOST CREDIT CARDS. WE OFFER INTEREST---FREE PAYMENT PLANS THROUGH CARE CREDIT for qualified applicants. It takes just minutes to prequalify at You may choose the 6---month interest free plan for services over $500 and, for services over $1500, either the 6 or 12---month plan. This offer is through Care Credit and may be discontinued at any time. PLEASE BE SURE TO HAVE ONE OF THESE FORMS OF PAYMENT WITH YOU AT THE TIME OF YOUR OFFICE VISIT. IF YOU DO NOT HAVE A FORM OF PAYMENT ON YOUR PERSON AT YOUR VISIT, WE WOULD BE HAPPY TO RE--- SCHEDULE YOUR APPOINTMENT. I understand that the responsibility for payment of services provided in this office for my dependents or myself is mine, due and payable at the time services are rendered and there will be no refund on services already rendered. In the event of a default, I promise to pay legal interest on the indebtedness, together with such collection cost and reasonable attorney fees as may be required to effect collection of this note. I have read, understand and agree to the Cancellation and Financial Policies detailed above. PRINT PATIENT NAME PATIENT SIGNATURE DATE Thomas Theocharides, MD / rev
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