Patient Registration | Aesthetics Forms Portal

Patient Information

First and Last Name: *

Date of Birth: *

Sex: *

Address: *

City/ State/ Zip: *

Email: *

Phone: *

Best method of contact?

Phone Text Email

How did you hear about us?

Why did you come see us today?

Patient Medical History

Are you pregnant or nursing at this time? *

When was your last menstrual period?

Have you had any history of the following conditions? (Past or Present)

Please indicate any previous surgeries or past hospitalizations within the last 6 months:

Please List Current Medications:

Please List Any Allergies:

If you drink, how much?:

If you smoke, how much?:

Dermatological Conditions?

Please specify/give details

Sensitive Skin?

Please specify/give details

Areas Of Concern:

Skin Type: (When exposed to the sun without protection for an hour)

1. Always burns never tans 2. Always burns sometimes tans 3. Sometimes burns or tans 4. Always tans 5. Hispanic Asian Mediterranean 6. African American

How would you describe your ethnic background?

Are you currently taking Accutane? *

Do you develop cold sores or fever blisters?

Do you develop or have any keloid scarring?

Emergency Contact Name/ Relationship *

Emergency Contact Phone Number: *

ANY ADDITIONAL NOTES / COMMENTS (Please use this box for ANY information we may need to know before your treatment):

Declaration

I declare that the information I have provided above is correct. I will inform OC Cosmetic and Vein Center if I develop any new medical conditions or there is any change in my medical history.

I certify that the information I have provided in this form is full and accurate to the best of my knowledge. *

Tap or click on the signature above to sign

Cancellation Policy

Although we always try our best to accomodate patients, our provider's time is valuable and as a respect and courtesy to them and other patients our company has the following cancellation policy:

We understand that sometimes emergencies happen and patients need to reschedule. There is no penalty for the first missed or rescheduled Laser Hair Removal, Exilis, or Microneedling treatment. After first missed treatment, if these appointements are cancelled less than 48 hours prior to appointment time, it will result in losing one treatment session of your package.

Cancellation Policy *

I understand that 48 business hours are required for cancellation of my appointment to avoid losing one session of my package.

Notice of Privacy Practices:

TO OUR PATIENTS:

This notice describes how health information about you, as a patient of this Practice, may be used and disclosed, and how you can get access to your health information. This is required by the Health Insurance Portability and Accountability Act of 1996.

Other Uses and Disclosures of PHI (Personal Health Information) Without Authorization: This Practice is permitted or required by the HIPAA privacy rule to use or disclose PHI without your written authorization as may be required by law or for the public-good. The uses and disclosures not otherwise described in this notice will only be made with your written authorization.

Your Individual Right:

Restriction Request: You have the right to request restrictions on the use and disclosure of PHI for treatment, payment or health care operations or that only certain individuals be involved in your care. Although the practice is not required to agree to such restrictions, we will accommodate reasonable requests, except when otherwise required by law.
Alternative Communication: You have a right to request alternate means communication. You may request that we contact you at a certain location or in a particular manner. We will accommodate reasonable requests.
Inspect and Copy: You have a right inspect and obtain a copy of your PHI and billing records. You must submit your request in writing to this practice's Privacy Official.
Amendment: You have a right to request an amendment to your PHI if you believe it is incorrect or incomplete. You must make your request in writing and submit it to the Privacy Official. You must provide us with a reason that supports your request for amendment.
Accounting: You have a right to receive an accounting of all disclosures of your PHI.
Paper Copy: You have a right to obtain a paper copy of this notice at any time.
Complaints: You have a right to file a complaint if you believe your privacy rights have been violated. This must be filled in writing with the Privacy Officer. You will not be intimidated, threatened, coerced or discriminated against for filing a complaint.
Privacy Officer: Any employee or physician of this Practice can provide you the name of the Privacy Officer, who can be reached at the address and telephone number on this document.
Effective Date: This notice takes effect upon acknowledgment by you.

The Medical Practice's Duties:

Legal Duties: This medical practice is required by law to maintain the privacy of your PHI and is required to abide by the terms of the "Notice of Privacy Practices".
Revisions: Revisions or amendments to this notice will be provided upon request and posted in the Reception Room.
Training: It is the responsibility of the practice to train its employees on current regulations. If they are unable to assist you, they will refer you to the Privacy Officer.
Right to Revoke This Authorizations: You may revoke this authorization at any time, except to the extent we have taken previous action based on the authorization.

Signature: *

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Date *