Patient Information. Patient Name Today s Date: Month Day Year. Mailing Address Street City State Zip Code

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Transcription:

Patient Information Patient Name Today s Date: First Middle Last Date of Birth / / Month Day Year Sex Race Ethnicity Pref. Language Mailing Address Street City State Zip Code Numbers BEST PHONE: Hm Wk Cell Other Phone: Hm Wk Cell Email Single Married Widowed Divorced Spouse s Name: Date of Birth: / / First Middle Last Month Day Year EmergencyContact/Relative Name Telephone Number Relationship: Parent/Legal Guardian First Middle Last Relationship to Patient Parent/Guardian Telephone Number: How would you like to receive appointment reminders? E-Mail Text Phone Call How did you hear about us? Internet Health Fair Yellow Pages Friend/Patient Other What are your major concerns for treatment today?

Medical History ALLERGIES CURRENT MEDICAL PROBLEMS Allergy Type of reaction (rash, hives, nausea, etc.) (high blood pressure, diabetes, etc.) 1. 2. 3. 4. 1. 2. 3. 4. CURRENT MEDICATIONS Medication and Dose 1. 2. 3. CONCURRENT TREATMENTS (within the last 4 months) Botox, Chemical Peel, Filler, Laser, Microderm,Vascular Lesions 1. 2. 3. Please Circle the appropriate response for the following questions: Do you get fever blisters or cold sores? Y N Do you bleed or bruise easily? Y N Do you have problems with scaring or keloids? Y N Do you take aspirin or blood thinners? Y N Have you been on Accutane in the last 24 months? Y N Do you use tanning Cream? Y N Do you use Sunscreen: Daily Always if Sunny Sometimes if Sunny Rarely/Never

Please Circle the appropriate response for the following items: Tanning History: Always burns, never tans Always burns, tans with difficulty Burns mildly, tans slowly Rarely burns, tans with ease Never burns, tans very easily Are you currently using any topical retinoids? Y N (Retinol, Tretinoin, Retin-A Micro, Differin, Atralin, Tazorac, Tri-Retinol) Do you currently use exfoliators? Y N (Salicylic, Glycolic, or Lactic Cleansers) Do you have any of the following: Personal history of skin cancer Personal history of atypical moles Family history of skin cancer Family history of atypical moles Acne History: Acne Scars Blackheads Enlarged Pores Flakiness Pimples Whiteheads Do you smoke? Y N How much? Are you currently pregnant? Y N Are you currently nursing? Y N

Missed Appointment/Cancellation Policy Effective September 2015 The providers at Premier Dermatology and Skin Renewal Center and The SPA at Premier strive to see all our patients in the most timely and convenient manner possible. As a courtesy, we attempt to contact every patient at least 24 to 48 hours prior to their scheduled appointment to remind them of the date and time. However, it is the responsibility of the patient to arrive for their appointment on time. For Skin Renewal Center Patients/Clients: (Cosmetic services) Patients/clients that do not contact us prior to missing their Skin Renewal Center appointment (at least 24 hours in advance) will be regarded as no show, and a charge of at least $35 will be assessed. Signature of Patient or Guardian Date For The Spa at Premier Patients/Clients: (Facials, Massages, Nails, etc.) Patients/clients that do not contact us prior to missing their The SPA at Premier spa appointment(s) (at least 24 hours in advance) will be regarded as no show, and will be charged for the amount of the service(s) missed. We do require a one (1) week cancellation notice for spa parties. If they are not cancelled within the one week timeframe, you will be charged for the services scheduled. Signature of Patient or Guardian Date

WRITTEN ACKNOWLEDGEMENT I am a patient of Premier Dermatology and Skin Renewal Center. I hereby acknowledge receipt of Premier Dermatology s Notice of Privacy Practices. Name [please print]: Signature: Date: OR I am a parent or legal guardian of [patient name]. I hereby acknowledge receipt of Premier Dermatology s Notice of Privacy Practices with respect to the patient. Name [please print]: Relationship to Patient: Parent Legal Guardian Signature: Date: PATIENT COMMUNICATION A. Family and Friends. It is the office policy of Premier Dermatology and Skin Renewal Center not to release confidential medical information regarding your treatment to family members or friends, except for (i) parent/legal guardian, (ii) other persons authorized by the patient, (iii) as we may reasonably infer from the circumstances (for example, if you bring a family member or friend into the exam room, we will assume, unless you object, that that person is entitled to receive information regarding your treatment), (iv) in emergency situations, or (v) other as otherwise permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). If you anticipate that you will need or want your medical information to be provided to family members, friends, or caretakers/babysitters, please indicate that below, so that we may best serve you. If you do not want any of your medical information provided to a family member, please check ( ) the line next to the "no" response. By signing below, you authorize the following people to receive information regarding your treatment or care. (If you wish to add names later on, please confirm this in writing, or call our staff.) Spouse: yes no Parent: yes no Other: yes no B. Alternative Communications. You are also entitled to specify alternative, reasonable means of communication, if you do not wish to be contacted by us in a certain way. I hereby request the following means of contact only: PRINTED NAME yes yes no no Patient/Parent/Guardian Signature: Date:

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