Microsoft word - newpatinfoform060209
NEW CLIENT INFORMATION FORM
Client Name: Last_________________________ First ______________MI____
Birth date ___/___/___ Age_____ Race_______ Sex_____
Home# ___________________Work#__________________Cell#_______________ We may call you to confirm your appt. Please use the numbers that you wish us to call.
We notify our customers about treatment specials and discounts on product by email.
(We do not disclose this information to anyone.)
Reason for visit____________________________________________ How did you hear about us?_____________________________ If referred by a friend, please let us know, as we offer a referral program.
If Yes, please explain____________________________________________________ Please indicate any reactions to medications, drugs, tape, rubber, latex and type of reaction i.e. hives, shock, etc____________________________________________ Please list all current medications and prescriptions:_________________________ ________________________________________________________________________
_____Facial surgery Hormones (females only): _____Regular periods
____During pregnancy, did you ever get hyper pigmentation or masking?
What do you want to improve about your skin? _____Fine lines
What home skin-care products care are you now using? ____________________________________________ ____________________________________________ ____________________________________________ Personal Health History: _____Excessive sun exposure _____Pregnant/lactating _____Connective tissue disorder or autoimmune disease _____Allergy to lidocaine (Xylocaine) _____History of serious allergies (anaphylaxis) _____History of facial cold sores or genital herpes _____History of hypertrophic scarring (thick, raised scars) _____Are you taking any mood altering or depression medication _____Bleeding tendency _____Use of blood thinner, aspirin, Motrin, Ibuprofen, or Naproxen _____Active inflammation or acne _____Communicable disease _____HIV or exposure to person with known HIV _____Hepatitis or known exposure to hepatitis A, B or C _____Taking immunosuppressive drugs, steroids _____History of Accutane use (in the past 6 months) _____ Other: _______________________________
Cancellations, Rescheduling and No Shows
As a courtesy, we make reminder calls to each of our scheduled clients the day
before a scheduled appointment using the information provided to us.
It is the responsibility of the client to inform us of any change of personal
information such as phone numbers, mailing address, e-mail address and any other pertinent information.
In consideration of our scheduled clients we ask that each client make every
effort to be on-time to their appointment. If a client is 15 minutes late or beyond we may need to reschedule the appointment for another day & time.
If an appointment needs to be cancelled or rescheduled we require a 24 hour
notice otherwise the client will be considered a no-show appointment.
If you fail to notify us of your need to cancel or reschedule within 24 hours of
your appointment date, you will be charged a $50.00 cancellation fee.
The information on this form is correct to the best of my knowledge. Signature:
Cap00-Goldwurm 4a bozza 1-06-2004 14:15 Pagina XQualità della Vita nella ricerca e nella societàLa ricerca sulla qualità della vita ha avuto un impulso notevole in campomedico soltanto quando si è diffusa la consapevolezza che, per valutare irisultati dei trattamenti in medicina, erano insufficienti gli abituali parametriclinici. Nella valutazione degli esiti, quindi, ci si è resi conto che
P R I M A R Y C A R E can both be characterized by loss of consciousness anda fall.9 Syncope is suggested by an onset while the pa-tient is erect and by a brief duration (10 seconds), EPILEPSY flaccid muscle tone during the event, pale color, coldand clammy skin, or electrocardiographic abnormal-ities. Tonic–clonic seizure is suggested by an onsetwhile the patient is asleep or awake and