NEW CLIENT INFORMATION FORM
DATE_____________________ Client Name: Last_________________________ First ______________MI____ Birth date ___/___/___ Age_____ Race_______ Sex_____ Address________________________________________________________________ City______________________State_________ Zip______________ Home# ___________________Work#__________________Cell#_______________ We may call you to confirm your appt. Please use the numbers that you wish us to call.
E-Mail address____________________________________________ 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. ALLERGIES?
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
NEW CLIENT INFORMATION FORM