Esthetician Services Registration Form

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Transcription:

Esthetician Services Registration Form PATIENT INFORMATION Name: Date of Birth: Address: Pharmacy: City, State, Zip: Phone #: Email Address: Medical Doctor: Home Phone: Phone #: Mobile Phone: Dermatologist: Work Phone: Phone #: Social Security #: Emergency Contact: Marital Status: Relationship to Patient: Occupation: Phone #: HISTORY 1. Of what ancestry are you? (English, Russian, etc.): 2. Do you have or have you ever had vitiligo (loss of skin pigment)?... Yes No 3. Do you currently have any skin disorders or challenges with your skin?... Yes No If yes, please explain: 4. Are you currently using or have you ever used Retin-A or Accutane?... Yes No If yes, when did you start? When did you stop? 5. Do you ever get herpes skin eruptions or cold sores?... Yes No 6. Do you have any physical injuries or conditions that require special attention?... Yes No If yes, please explain: 7. Are you currently under the care of a dermatologist?... Yes No 8. Have you ever had a facial, dermabrasion treatment or a chemical peel?... Yes No If yes, when, where, and by whom? 9. Have you ever had a reaction to any products or treatments?... Yes No If yes, please explain: 10. Do you currently have a skin care regimen at home?... Yes No If yes, please tell us about your products and routine: 11. Are you happy with your current skin care products?... Yes No MEDICAL HISTORY: Please check the box if you have, or have been treated for: Bleeding disorder Circulation problems Thyroid problems Endocrine/hormonal Lung problems High blood pressure Diabetes Other: Stroke Cancer Skin problems

Esthetician Services Registration Form - Page 2 SURGICAL HISTORY: Please list any surgeries, including cosmetic procedures and laser treatments, and the date(s): MEDICATIONS: List your current medications and dosages. Please include all prescriptions (pills, creams, gels), over-the-counter medications, and herbal supplements of any form (use the back of this form if needed): Are you allergic to any medications, topical creams/ointments, foods, latex, or adhesives?... Yes If yes, please list the medication and reaction: No SKIN TYPE: Circle one from each column. TYPE SKIN TYPE EYES HAIR COLOR REACTION TO FIRST SUN EXPOSURE I Very light Blue Red Always burn, never tans II Light Green Blonde Usually burn, tan with difficulty III Medium Brown Light brown Sometimes mild burn, tan average IV Medium-dark Black Brown Rarely burn, tan with ease V Dark brown Rarely burn, tan very easily VI Black Never burn, tan very easily 1. Do you ever experience these conditions in your skin?... Flakiness Tightness Obvious dryness 2. Do you burn easily in moderate light?... Yes No 3. Do you blush easily when nervous?... Yes No 4. Do you typically have facial redness?... Yes No 5. Do you suffer from sinus problems?... Yes No 6. Do you experience oily shine during the day?... Yes No 7. Do you ever experience skin breakouts?... Yes No 8. Do you ever experience a burning or itching sensation in your skin?... Yes No 9. What is your pain threshold?... Low Medium High 10. Have you ever experienced claustrophobia?... Yes No LIFESTYLE 1. Are you pregnant or trying to become pregnant?... Yes No 2. Are you lactating?... Yes No 3. Are you taking oral contraceptives?... Yes No 4. Do you smoke? Yes No... If yes, how many packs per day? 5. Do you drink alcohol? Yes No... If yes, what is your weekly average consumption? 6. Do you drink caffeinated beverages (coffee, tea, etc.)? Yes No... If yes, how many cups per day? 7. How many cups of plain water do you drink per day?

Esthetician Services Registration Form - Page 3 8. Do you exercise regularly?... Yes No 9. Do you have metal implants, a pacemaker, or body piercings?... Yes No 10. What SPF sunscreen do you use?... Face SPF: Body SPF: 11. Do you sunbathe or use tanning beds?... Yes No 12. Do you follow a restricted diet?... Yes No 13. Do you wear contact lenses?... Yes No 14. Rate your level of stress on a scale of 1 to 4 (1= low, 4= high):... 1 2 3 4 HELP ME SERVE YOU BETTER Please number in order of importance (1 = least important, 4 = most important): Relaxation and pampering Renewed appearance/anti-aging Deep pore cleansing Information on skin health Do you love information and want to know about every part of your treatment?... Yes Are you here to get a little peace and want to leave it to the expert?... Yes No No EXPECTATIONS & PREFERENCES What are your personal skin care goals? If you could change one thing about your skin, what would it be? What type of massage do you prefer: light, medium, or firm? Tell me what your favorite part of a facial is: ADDITIONAL COMMENTS The information above is true, complete, and accurate to the best of my knowledge. Client/Guarantor Esthetician

RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS All Patients: I authorize the release of any medical information necessary to process this claim. I also authorize payment of medical benefits or cosmetic services directly to Enzer & Associates, P.C. In the event you are required to proceed with any collection proceedings, I agree to be responsible for all reasonable billing fees associated with the collection of my debt, including but not limited to 1.5% per month interest on the outstanding balance, plus attorney and/or collections fees (up to 33.3%). I agree that I will be responsible to pay Dr. Enzer for all services rendered, including those not covered, co-insurance balances, or denied for payment by my insurance company. Medicare Patients: I request that payment of authorized Medicare benefits be made to Enzer & Associates, P.C. for any and all services furnished to me by said medical company. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services. MISSED APPOINTMENT POLICY Any appointment missed, cancelled, or rescheduled less than 24 hours will be subject to the following fees. PLEASE NOTE: leaving a message with our answering service the night before a scheduled appointment does not constitute a 24 hour notice. Dr. Enzer: Follow-up = $50.00 New Patient = $100.00 Minor Procedure (20 minutes) = $100.00 Major Procedure (30+ minutes) = $150.00 Registered Nurse or Licensed Esthetician: One half of treatment cost Appointment fees may be charged to a Visa or MasterCard. Should you wish to be billed, there will be an additional $25.00 fee from our billing company. All appointment fees must be paid in full prior to booking another appointment. I have read and agree to the terms of the appointment policy as stated above. PATIENT PHOTOGRAPHY CONSENT Photographs are an integral part of your medical record in our office. I,, hereby give my permission to Enzer & Associates, P.C. to photograph me for diagnostic purposes, medical records, and to release copies of these photos for insurance billing requirements. In addition these photos may be used for teaching purposes, illustration of scientific papers or medical books, or published on our website photo albums. Enzer & Associates PC will take all safeguards to protect my privacy and confidentiality in the use of these photographs. I hereby consent to release any photo other than a full face frontal or side ( identifying ) photo for the uses above without inspection or approval on my of the finished product or specific use to which these photographs may be applied. I agree to let Enzer & Associates, PC release any photographs, including identifying photographs, only to comply with medical insurance guidelines. Revised 10/12

HIPAA ACKNOWLEDGEMENT AND PRIVACY PREFERENCES I,, understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I have had the opportunity to read and understand your Notice of Privacy Practices regarding the uses and disclosures of my health information (a hard copy is not been enclosed; please ask receptionist if you wish to read the full text or receive a hard copy). I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I may also request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I give my permission to be contacted by the following option(s): Home phone Y N May we leave a message? Y N I do NOT give my permission to be contacted by Enzer & Associates, PC. I assume full financial responsibility for any and all missed appointments. Cell phone Y N May we leave a message? Y N Work phone Y N May we leave a message? Y N Mail Y N Email Y N Revised 10/12

Directions to Southside Medical Center at 120 Dudley Street Driving North on I-95: Take exit 18 for Thurbers Ave. Bear left onto Thurbers Ave. and turn right at the first light onto Eddy St. After.08 mi. turn left onto Dudley St. Free parking is in gated lot on left, directly across from Women & Infants Hospital. We are on the first floor in Suite 104. Driving South on I-95: Take exit 19 for Eddy Street immediately after the split for I-195. Bear left on the exit towards Eddy St. Merge right onto Eddy St., and then turn right at the 1st light onto Dudley St. Continue 1/4 mi. on Dudley St. Free parking is in gated lot on left, directly across from Women & Infants Hospital. We are on the first floor in Suite 104. Driving West on I-195: Merge onto I-95 South and take exit 1B (the first exit on the right) for Eddy St. At the light turn right onto Eddy St. At the next light take a left onto Dudley St. Continue on Dudley St. for 1/4 mi. Free parking is in gated lot on left, directly across from Women & Infants Hospital. We are on the first floor in Suite 104. Policies Office Hours: Our normal hours are 9:00 a.m. to 5:00 p.m. Monday through Friday. However, you may call the office any time and all emergencies will be relayed to Dr. Enzer immediately. Appointments: All visits are scheduled by appointment. It is our policy to book ample time for your visit with Dr. Enzer and we do our best to minimize patient waiting time. If you should need to cancel or reschedule an appointment, we require at least 24 hours advance notice; otherwise you will be responsible for the visit fee and any other necessary billing or collection fees. Registration Materials: In order to provide optimum care, Dr. Enzer requests that you complete a medical history questionnaire prior to your visit with our office. You may do this by downloading the registration forms from www.doctorenzer.com, requesting them by mail, or coming to the office ten minutes early to fill out the forms. Please bring a complete medication list to your visits. If you wear contact lenses, you should bring a case for them as well as your glasses. Insurance Coverage: For our medical patients, Dr. Enzer participates with the major area plans. Many plans require that the patient obtain permission to see Dr. Enzer for the initial and each follow-up visit. This is your responsibility. Please bring your insurance card (s) to the office so we can obtain accurate billing information. If your insurance plan decides not to cover Dr. Enzer s services, you will be responsible for payment of the bill. To contain costs, all payments are required at the time of service. We accept cash, checks, VISA or MASTERCARD. There is a billing fee for any unpaid balances. By minimizing our expenses, we help keep our fees competitive. Reconstructive Procedures: Many reconstructive procedures will be covered by insurance plans. Our staff will help obtain this information in advance if possible. We make no representation or guarantee regarding what costs an insurance company will cover. All non-covered services will be the responsibility of the patient. Cosmetic Surgery Costs: The cost of cosmetic surgery is not covered by insurance plans, and thus is the full responsibility of the patient. For more information regarding cosmetic surgery policies and fees, please go to the Office Policies section on our website at www.doctorenzer.com.

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