Microsoft word - 2013 - new patient form history.doc

Patient Registration
YOU ARE ALREADY FLAWLESS, WE HELP YOU STAY THAT WAY!
Name__________________________________ Birthdate __________________ Age ______ Sex M / F Address______________________________________________________________________________ Patient’s Employer __________________________________________Occupation ______________________ Primary Doctor _______________________________
Primary Dr. Telephone # _________________________
Areas of Interest Regarding Your Skin:
 Other:___________________________________________ How did you hear about us?
 Salon  Web/Google  Facebook  Pride Guide  Groupon
Referral Program – Please let us know who told you about Flawless so we can reward them with
some Flawless Dol ars!

_____________________________________________________________________________

How to contact you: We take your privacy very seriously. If we need to contact you regarding your care,
please identify the best way to reach you.
If we are unable to speak directly with you, please list spouse, family members or friends with whom we can
speak regarding your appointments, surgical dates, or other personal health information.

Telephone #_________________ Relationship______________ Whom should we contact in the event of an emergency?
Telephone #_________________ Relationship______________ Current Medical Conditions
Have you ever seen a physician for any of the fol owing conditions? (Check all that apply)
Please list any other conditions for which you are or have been under a physician’s care:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Current Medications:
Are you taking any of the fol owing medications? (Check all that apply.)
Please list any other medications you are presently taking:
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Please list any known al ergies to medication, foods, etc:
____________________________________________________________________________
____________________________________________________________________________
(*) Are you pregnant, possibly pregnant or considering pregnancy in the near future?
______Yes ______No
(*) Are you lactating?

Skin Protocol:
Please circle the category that best describes your skin color and tendency to sunburn:
 I. Very white or freckled always sunburn.  II. White usual y sunburn  II . White to Olive sometimes sunburn  IV. Brown rarely sunburn  V. Dark Brown very rarely sunburn  VI. Black never sunburn
Please circle the category that best describes your skin type:

 I. Problematic (Acne, Psoriasis, Rosacea, Eczema)  II. Oily  II . T-zone or Combination Skin  IV. Normal  V. Dry  VI. Sensitive (Al ergic reactions to some skin care products)
Previous Cosmetic Facial Treatments:
I have answered these questions truthfully and will notify ALC of any changes in medications or my physical conditions. I have received or viewed on-line a copy of the ALC Privacy Policy. If I have given permission to leave detailed messages, fax or e-mail information regarding my care, and/or discuss my medical care with specific family and/or friends, I understand that I am granting a waiver of my privacy rights under HIPAA. If I decide to change these instructions, I wil notify ALC in writing as soon as possible. If I have given my email address above, I understand that email is not privacy protected. Patient Signature________________________________________ Date ___________________ Patient Name_____________________________________________ DOB_________________

Source: http://www.stayflawless.com/file/2013_-_New_Patient_Form_History.pdf