PATIENT INFORMATION FORM
|
|
- Brice Quinn
- 6 years ago
- Views:
Transcription
1 PATIENT INFORMATION FORM PATIENT DATA DATE: Last First MI: Date of Birth: Social Security #: Gender: Female Male Marital Status: PHONE Home: Preferred Home Work Cell Work: Is it okay to leave a detailed message: Yes No Mobile: May we you for appointment reminders? Yes No Would you like to receive our Bella Vista newsletter? Yes No ADDRESS Address: City: State: Zip: EMPLOYMENT Employer: Occupation: INSURANCE Primary Insurance Company: Secondary Insurance Company: GUARANTOR/BILLING INFORMATION: SAME AS ABOVE: Patient Relationship to the Guarantor: Guarantor Last First MI: Guarantor Date of Birth: Guarantor Social Security #: Guarantor Gender: Male Female Guarantor Home Phone: Guarantor Address: PHARMACY Pharmacy City State Zip Pharmacy City: PRIMARY CARE PHYSICIAN Physician Phone: REFERRAL How did you hear about us? Internet Our Website Insurance Company Advertisement: Physician Referral: Family/Friend: Other: EMERGENCY CONTACT Number:
2 PATIENT HEALTH QUESTIONNAIRE All information collected in this questionnaire is strictly confidential and will become part of your medical record. Have you had any previous surgeries? If so, what and when? (Operations and Cosmetic Surgery) Type Date Complications or Difficulties Medical problems or conditions now under treatment by a Physician. Explain Admissions to Hospital Reason Date Complication or Difficulties Are you currently on prescription medication? If yes, please provide details below or attach a list. Type Dosage/Amount Take how often Do you take over-the-counter drugs, vitamins, supplements, or use inhalers? If yes, please provide details below. Type Dosage/Amount Take how often Do you bruise or bleed easily? (With cuts/tooth extractions/pregnancy/surgery) Explain: ifficulties with local or general anesthesia? xplain: Have you ever had a blood transfusion? Are you Pregnant? Are you allergic to any medication? If yes, please provide details below or attach a list.
3 PATIENT HEALTH QUESTIONNAIRE Past Medical H istory Heart Disease Stroke Asth ma Diabetes ENT Hearing Loss Sinus Pain/Pressure Voice Change Swallow ing difficulty Cancer Cardiovascular Thyroid Disease Kidney Disease Sleep Apnea Chest Pain Ankle Swelling Irre g u la r He a rtb e a ts GERD Ophthalmologic Blood D isorders High Blood Pressure Eye Pain Double Vision Family H istory Dry Eyes Allergy Dermatologic Cancer Diabetes Heart Disease Rash Hair Loss Growth/Spots Stroke Musculoskeletal Hearing Loss Bleeding D isorders Keloid Formation Social H istory Alcohol Weakness Jo in t Pain Muscle Pain Gastrointestinal Abdominal Pain If y e s, h ow ma n y p e r d ay? Drinks/Glasses Nausea Smoking Heartburn If y e s, h ow ma n y p e r d ay? Packs/Cigarettes Genitourinary Illic it D ru g Us e Pain w ith U rination If s o, e x p la in : Frequent U rination Constitutional Pelvic Pain Fever Neuro/Psych Chills Weight Loss Headache Dizziness Night Sweats Anxiety Respiratory Depression Sho rtness of B reath Cough Wheezing
4 COSMETIC QUESTIONNAIRE LET US KW IF YOU RE INTERESTED IN Last First MI: Date: Skin Rejuvenation Wrinkles BOTOX Cosmetic Restylane Dysport Juvéderm Radiesse Sculptra TCA Peels Lip Augmentation Eyelid Contouring (Blepharoplasty) Full or Mini Face Lift Brow Lift Neck Liposuction Chin Augmentation Hair Transplant Primary Rhinoplasty Secondary (Revision) Rhinoplasty Ethnic Rhinoplasty Ear Pinning (Otoplasty) Other: WHAT WOULD YOU LIKE TO IMPROVE?
5 PATIENT CONFIDENTIALITY AGREEMENT In order to comply with HIPAA standards and give our patients the best medical treatment possible, we require that a patient give us the authorization to discuss their medical records with any referring and/or referred medical providers. Please list medical providers below: Practice Practice In the event you are unable to be contacted by our office, please indicate any family member or friend that we can release any or all information relating to your medical condition. By signing this agreement you allow Bella Vista ENT & Facial Plastic Surgery (Dr. Glenn Waldman & Dr. Jeffrey Feinfield and their staff) access to your medical records; the release of your records to the above listed Physicians; and the release of medical information to the parties listed above. PATIENT/GUARDIAN SIGNATURE DATE PRINTED NAME
SALIBIAN MOSSI. Name Last First Middle. Address Apt. City State Zip. Home Phone Cell Phone Work Phone. Address
Name Last First Middle Address Apt. City State Zip Home Phone Cell Phone Work Phone Email Address Age Date of Birth Sex Height Weight Marital Status Drivers License # Social Security # Employer Occupation
More informationHow did you hear of us? Friend: Our patient: Magazine: Physician referral:
Patient Information Today s Date: Title: Dr. Mr. Mrs. Ms. Name (Last, First, Middle) Gender: M F Age: Birthdate: Social Security: Street Address City, State & ZIP Home Phone Cell Phone Work Phone Email
More informationCOLORADO AESTHETIC CENTER
COLORADO AESTHETIC CENTER 9320 Grand Cordera Parkway, Suite #250 Colorado Springs, CO 719.387.7800 Skin and Health Questionnaire Please answer the following questions thoroughly, as this provides a better
More informationPatient Information. M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Whom may we thank for referring you?
Today's : First Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Patient Information Last Name Email: Primary Care Physican:
More informationDr. Paul L. Leong PATIENT MEDICAL HISTORY
Fax: 412.226.5176 Dr. Paul L. Leong PATIENT MEDICAL HISTORY Name: Age: Appt. Date: Address: City: State: Zip Code: _ Email:Date of Birth: Phone Number: Home ( ) Cell ( ) Social Security # Sex: Male: Female:
More informationHealth Questionnaire
Health Questionnaire Please Complete All Sections of This 4 Page Questionnaire Skin History: Skin Care Concerns: Facial Veins Facial lines or wrinkles Uneven skin texture Facial Redness (Rosacea) Brown
More informationAreas of Concern. Patient s Name Last First Date
Areas of Concern What are your main concerns for today s visit? Please check the problem areas that concern you. Include anything you wish to discuss, even if it is not the main reason for your visit.
More informationImbue Aesthetics & Wellness PATIENT REGISTRATION FORM
Today's Date Legal Name Marital Status Sex DOB Age Mailing Address Preferred Phone Number Email Do we have your permission to add you to our email list to receive newsletters and promotions? YES NO Emergency
More informationTouch Up-Color Refresh Policy
Touch Up-Color Refresh Policy All Full Price New Procedures clients receive one Follow up visit for $50 with your initial price per procedure. You must wait at least 30 days before you can be touched up.
More informationS Main St, Kaysville, UT 84037
MEDICAL HISTORY Date Name Age Date of birth: Email: Address City State Zip Home Phone Work or CellPhone Preference number for contact (appointment reminders or other) Primary Physician s Name and Number
More informationCOSMETIC INTEREST QUESTIONNAIRE
COSMETIC INTEREST QUESTIONNAIRE Patient Name: Date: General appearance or products of interest to you (please check all that apply). Skin care consult Facial veins Neck elasticity Skin care products Facial
More informationCLEAR TOE INTAKE INFORMATION
CLEAR TOE INTAKE INFORMATION Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: Female Male Home Phone: Cell Phone: Leave messages at: Home Cell Other: Email address:
More informationInformed Consent for Dermal Filler
Informed Consent for Dermal Filler NAME: DATE OF BIRTHG: ADDRESS: CELL PHONE: EMAIL: www.medicaleyecenter.com Please initial all of the following sections confirming that you have read and understand each
More informationIf you are coming in for a spa treatment or to see one of our nurses for a medical treatment, please arrive 15 minutes prior to your appointment.
Welcome to Nayak Plastic Surgery and Avani Day Spa! We specialize in Facial Plastic Surgery, Skin Care, and Spa Treatments. Our cosmetic services include laser treatments, such as wrinkle reduction, age
More informationCosmetic Surgery: Eyelid Surgery (Blepharoplasty)
Cosmetic Surgery: Eyelid Surgery (Blepharoplasty) This is a guide for people who are considering an eyelid surgery. We advise that you talk to a plastic surgeon and only use this information as a guide
More informationClient Intake Form. Name: Date: Address: City: ST: Zip: Phone:
Client Intake Form Name: Date: Last First Address: City: ST: Zip: Email: Phone: How did you hear about Skin Renew Day Spa? What are your main concerns? How long have you been experiencing your current
More informationPATIENT INFORMATION FORM
PATIENT INFORMATION FORM Name: (Last) (First) (M.I.) Sex: (M / F) SSN (Required for Weight Loss Program): Birth : Age: Home Address: City: State: Zip Code: Home Phone: ( ) Cell Phone: ( ) Best number to
More informationBlepharoplasty does not alter dark circles, sagging eyebrows or fine lines and wrinkles around the eyes but it does improve drooping eyelids.
Dr. Tuan V. Pham M.B.B.S., F.R.A.C.S. Facial Plastic & Reconstructive Surgeon Aesthetic Plastic Surgeon Nasal, Sinus & Rhinoplasty Surgeon Head & Neck Surgeon Level 1, 136 Churchill Ave, SUBIACO Western
More informationNewport Cosmetic Center
Shirin Afrasiabi, M.D, Inc. 2301 Newport Blvd, Costa Mesa, Ca 92627 (949) 548-5700 Appointment: Initial. We require a valid Credit Card at the time of booking to secure your appointment Cancellation and
More informationForm of free consultation Cosmetic Surgery
Form of free consultation Cosmetic Surgery EstetikaTour 17, rue Ahmed Rami 1002 Bélvedére - Tunisie * The Heading that should be filled. Your personal details : Title* : Mrs Miss Mr Family name* :.. First
More informationWelcome to Medspa 1064, Connecticut s Premier Center for Cosmetic Laser Medicine
MedSpa 1064 Suites at Somerset Square 140 Glastonbury Blvd. Glastonbury, CT 06033 860.657.1064 Welcome to Medspa 1064, Connecticut s Premier Center for Cosmetic Laser Medicine This form is to introduce
More informationCLIENT QUESTIONNAIRE TODAY S DATE: SPECIFIC CONCERNS REGARDING YOUR SKIN (CHECK ALL THAT APPLY) I AM INTERESTED PRIMARILY IN:
CLIENT QUESTIONNAIRE TODAY S DATE: NAME: DATE OF BIRTH: SPECIFIC CONCERNS REGARDING YOUR SKIN (CHECK ALL THAT APPLY) Fine Lines/Wrinkles Dark Circles Puffy Eyes Blotchiness/Discoloration Uneven Skin Tone
More informationHair loss checklist. 1. Hair loss patient history from received and completed
Hair loss checklist 1. Hair loss patient history from received and completed 2. Complete the attached medical release form: include all doctors that have checked lab work, performed biopsy or evaluated
More informationHair Loss/Hair thinning/alopecia Patient History Form
Hair Loss/Hair thinning/alopecia Patient History Form We take hair loss very seriously due to the large impact it has on a patients quality of life. We therefore devote an alopecia clinic appointment for
More information5504 Backlick Road Springfield, Virginia
Name: Address: Phone: City: Zip Code: Cell: Phone: Text Cell Phone email How did you hear about us: General Health State: Contact me by 1. Rate your level of stress: (5 = highest, 1= lowest) 5 4 3 2 1
More informationNEW CLIENT GENERAL INFORMATION FORM
NEW CLIENT GENERAL INFORMATION FORM First Name: Last Name: Email: Date of Birth: Occupation: Home Phone: Cell Phone: Carrier: Gender: Female Male Preferred Staff Gender: Female Male Preferred Staff Member:
More informationLast Name: First Name: Address: Apt: City: State:
Today s date: Estimated Weight Height Last Name: First Name: Address: Apt: City: State: Zip Phone: (H): (C) (W) Email: Please note, email will not be given to others and will only used for reminders and
More informationINFORMED CHEMICAL PEEL CONSENT. 1. I authorize the chemical peel listed above, to my face and / or neck, chest and hands.
INFORMED CHEMICAL PEEL CONSENT 1. I authorize the chemical peel listed above, to my face and / or neck, chest and hands. 2. Depending on the chemical peel site, there may be redness and/or irritation and
More informationAlani Medical Spa Medical History and Information
Alani Medical Spa Medical History and Information Birth date: _/_/_ SS#/_/_Email_ Today s Date: _/_/_ Name: (Mr.) (Mrs.) (Miss) Home Address: _ Work Address: _ Home Phone: ( ) Work Phone: ( ) _ Phone Number
More information513 Maple Ave West, Vienna, VA
CLIENT INFORMATION AND CONSENT FORM: SKIN CARE Name Date of Consultation Address City State Zip Home phone ( ) Cellular phone ( ) E-mail Date of birth Emergency contact and telephone number How did you
More informationClient Information & Health History
Client Information & Health History Name: Address: City: State: Zip Code: Cell#: Work#: Home#: Email: Preferred method of contact: email cell# work# home# Date of Birth: Occupation: How did you hear about
More informationMassey Medical. Medical History (Dermal Filler) MEDICAL INFORMATION: I am interested in the following services: Juvederm: Botox:
Medical History (Dermal Filler) Name: Date: _ Date of Birth: Phone: _ MEDICAL INFORMATION: I am interested in the following services: Juvederm: Botox: NO YES Allergies history of severe allergy or anaphylaxis.
More informationLaser Skin Resurfacing what to expect
Laser Skin Resurfacing what to expect Laser skin resurfacing is a treatment to reduce facial wrinkles and skin irregularities, such as blemishes or acne scars. The technique directs short, concentrated
More informationWelcome to Bella! Give the Gift of Bella. A few tips to prepare you for your first visit: Gift Certificates are just $100 for a $150 value!
Welcome to Bella! We are glad to have you as our guest. We encourage you to visit our website to see all of the exciting new laser and skincare treatments that we offer. Please be aware of our 24 hour
More informationContact Information. Idaho Falls. Idaho Falls, ID (208) (307) NAME. City / state / zip
Contact Information NAME physical street address City / state / zip Home phone cell phone email address want monthly specials? date of birth Age gender Male female How did you hear about us? WHICH AREAS
More informationAmerican Academy of Cosmetic Surgery 2008 Procedural Census
American Academy of Cosmetic Surgery 2008 Procedural Census Prepared by: RH Research February 2009 2008 AMERICAN ACADEMY OF COSMETIC SURGERY (AACS) PROCEDURAL CENSUS KEY FINDINGS The estimated total number
More informationEnhancing your appearance with a facelift
PROCEDURE FACT SHEET PLASTIC SURGERY FACELIFT This is a guide for people who are considering a facelift surgery. We advise that you talk to a plastic surgeon and only use this information as a guide to
More informationDate: Date of Birth: Gender: Male Female. City: State: Zip: Caucasion a African-American Hispanic Asian East Indian American Indian
Contact Information: Date: Date of Birth: Gender: Male Female Name: Address: City: State: Zip: Home Phone: Work/Day Phone: Cell: Email: Emergency Contact: Emergency Contact Phone: Medical Background Ethnic
More informationMicroblading Consent and Release Agreement
Microblading Consent and Release Agreement This form is designed to give information needed to make an informed choice of whether or not to undergo a Microblading semi-permanent make up application. If
More informationHEALTH HISTORY INFORMATION
HEALTH HISTORY INFORMATION Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: Female Male Home Phone: Cell Phone: Leave messages at: Home Cell Other: Email address:
More informationCOSMETIC LASER AND AESTHETICS CENTER
COSMETIC LASER AND AESTHETICS CENTER PERSONAL INFORMATION Please complete the following: Date: Name: Date of Birth: Home Address: City: State: Zip: Home Telephone: ( ) Cell: ( ) Work Phone: ( ) Email This
More informationSTATEMENT OF CONSENT AND RECITALS: Please read and initial all lines. Signed
STATEMENT OF CONSENT AND RECITALS: Please read and initial all lines Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow
More informationName DOB / / SS# Last First MI. Address City State Zip. Home Phone( ) Employer Work Phone( ) Emergency Contact & Relation Phone( )
Paul E. Goco, MD Board Certified Facial Plastic Surgeon Nicole D. Wissing, MS, PA-C Physician Assistant Mandi Perry Mia Jones Tricia King Licensed Aestheticians 1370 Gateway Blvd., Suite 240 Murfreesboro,
More informationHair To Bare South. Client Name: Date:
Hair To Bare South Client Name: Date: I authorize Rachelle Stokes (Hair To Bare South) to perform the treatments. The purpose of these treatments is to diminish or remove unwanted hair. The quantity of
More informationPersonal Profile and Health History
--CAPITAL AESTHETICS Personal Profile and Health History Name: Home Phone: Address: Work Phone: City/State/Zip: Date of Birth: Age: Gender: M F Occupation: Email address: How did you hear about us? What
More informationAmerican Academy of Facial Plastic and Reconstructive Surgery 2006 Membership Survey: Trends in Facial Plastic Surgery
American Academy of Facial Plastic and Reconstructive Surgery 26 Membership Survey: Trends in Facial Plastic Surgery February 27 AAFPRS 31 South Henry Street Alexandria, VA 22314 Phone: (73) 299-9291 Web
More informationMARK D. EPSTEIN, M.D. F.A.C.S. Hyaluronic Acid (HA) INJECTION - INFORMATION FOR PATIENTS
Hyaluronic Acid (HA) INJECTION - INFORMATION FOR PATIENTS INSTRUCTIONS This is an informed-consent document which has been prepared to help you understand hyaluronic acid (Juvederm, Restylane, Belotero)
More informationEYELID SURGERY. What is Eyelid Surgery? Consultation & Preparing for Surgery. The Procedure Risks & Safety Recovery After Surgery / Results
EYELID SURGERY What is Eyelid Surgery? Consultation & Preparing for Surgery The Procedure Risks & Safety Recovery After Surgery / Results WHAT IS EYELID SURGERY? Eyelid surgery, called blepharoplasty,
More informationINJECTABLES. Botox Cosmetic Page 1 of 7. FAQ s
290 Country Club Drive, Stockbridge, Georgia 30281 770.506.9123 www.schillingmedicalspa.com FAQ s INJECTABLES Botox Cosmetic WHAT EXACTLY IS BOTOX COSMETIC? BOTOX Cosmetic is a purified protein produced
More informationA S A P S S T A T I S T I C S O N C O S M E T I C S U R G E R Y
TH E AME RICA N SOCIETY FOR AESTHE TIC PLAST I C SURGERY, IN C. A S A P S 2 0 0 0 S T A T I S T I C S O N C O S M E T I C S U R G E R Y Introduction to ASAPS Statistics Quick Facts: Highlights of the ASAPS
More informationBrow and Beauty Bar - Permanent Makeup
General Consent and Procedure Permit Clients Full Name Mr/Mrs/Miss/Ms Address e-mail I hereby authorize Erin Exline to perform upon myself permanent cosmetic enhancement. If any unforeseen condition arises
More informationInformed Consent For Facial Rejuvenation/Collagen Remodel
Informed Consent For Facial Rejuvenation/Collagen Remodel Client s name: Date: I authorize SilkySkin Laser Centers to perform the laser procedure. You will be treated with the Cynosure Elite TM laser,
More informationIntake Form Chemical Peels, Microdermabrasion, and Facials
Intake Form Chemical Peels, Microdermabrasion, and Facials Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: 0 Female 0 Male Home Phone: Cell Phone: Leave messages
More informationClient Information Sheet
Esthetic Laser Clinic 8381 Old Courthouse Road Suite 300 Vienna, VA 22182 (703) 288 0085 www.elaserclinic.com Client Information Sheet Last Name First Name: Address City State Zip Code D.O.B. (MM/DD/YY)
More informationRefresh, Renew Rejuvenate Look years younger, with minimum downtime. The Quick-Recovery Facelift
Refresh, Renew Rejuvenate Look years younger, with minimum downtime. The Quick-Recovery Facelift Discover How Easy Looking Younger Can Be. We have pioneered an exciting new facelift procedure that offers
More informationNATIONAL CLEARINGHOUSE
AMERICAN SOCIETY OF PLASTIC SURGEONS 2009 REPORT of the STATISTICS NATIONAL CLEARINGHOUSE of Plastic Surgery Statistics Established 1931. The Symbol of Excellence in Plastic Surgery Phone 847-228-9900
More informationPatient Information Leaflet. Dermal Filler
Patient Information Leaflet Dermal Filler When considering treatment with dermal fillers we want you to have a safe treatment. Some risks are unavoidable and out of your control. The following information
More informationMaya Med Spa 6330 Broadway Blvd. Suite B, Garland, TX Name: Date of birth: Address: Pharmacy of your choice:
Client Consultation Name: Date of birth: Address: Home Phone: Cell Phone: Business Phone: E-mail address: Married: Yes No If yes, anniversary date: Employer: Occupation: Pharmacy of your choice: Does your
More information2019RICHMOND, VIRGINIA
2019RICHMOND, VIRGINIA 39 th Contemporary Facial Rejuvenation Live Cosmetic Surgery Workshop P R E S E N T E D B Y JOE NIAMTU, III,DMD, FAACS MARCH 1-3, 2019 20 hours of AMA PRA Category 1 CME credits
More informationConsent and Release Agreement
Consent and Release Agreement This form is designed to give information needed to make an informed choice of whether or not to undergo a 3D Eyebrow Embroidery Semi-permanent make up application. If you
More informationGet Rewarded for Looking Your Best * ASPIRErewards.com. *Terms and conditions apply. See details at
Get Rewarded for Looking Your Best * ASPIRErewards.com *Terms and conditions apply. See details at www.aspirerewards.com. Discover the difference with ASPIRE Galderma Rewards It s the rewards program you
More informationCLIENT HISTORY. May we contact you at these numbers?
CLIENT HISTORY Name: Address: Home Phone: Cell Phone: Email Address: Date of Birth: Street City State Zip Business Phone: May we contact you at these numbers? Other ID: Referred by: Emergency Contact:
More informationGALDERMA UNVEILS NEW DIRECT-TO-CONSUMER CREATIVE CAMPAIGNS FEATURING REAL WOMEN, REAL RESULTS
GALDERMA UNVEILS NEW DIRECT-TO-CONSUMER CREATIVE CAMPAIGNS FEATURING REAL WOMEN, REAL RESULTS Campaigns Empower Women to Embrace Their Desire to Look Their Best with Products that Provide Natural-Looking
More informationMedication Name Reason Taken Dosage Last Date Taken
CLIENT HISTORY FORM Print Name Location of Service: Email Birth Date Age Gender @ Female Address City State / Male Emergency Contact Name and Number Home Phone ( ) Cell Phone ( ) Today s Procedure Description:
More informationClient Questionnaire Skin & Health
Client Questionnaire Skin & Health Please answer the following questions thoroughly and completely, as this provides a better understanding of your general health, lifestyle and skin care concerns; thereby
More informationThe first step: Choose a surgeon you can trust COPYRIGHT ASPS
/ INJECTABLE FILLERS The Symbol of Excellence in Plastic Surgery A public education service of the American Society of Plastic Surgeons. The first step: Choose a surgeon you can trust Plastic surgery involves
More informationInformed Consent for Light Energy Tattoo Removal
Dr. Joseph G. Protain 813 Kentwood Dr. Boardman, OH 44512 (330)953-3515 Informed Consent for Light Energy Tattoo Removal Customer s name: Date: I, consent to and authorize and members of his/her staff
More information2017RICHMOND, VIRGINIA
2017RICHMOND, VIRGINIA Contemporary Facial Rejuvenation Live Cosmetic Surgery Workshop P R E S E N T E D B Y JOE NIAMTU, III,DMD, FAACS September 15-17 2017 19 hours of AMA PRA Category 1 CME credits www.lovethatface.com
More informationNEWS RELEASE. CONTACTS: Investors: Lisa DeFrancesco (862) Media: Mark Marmur (862) Ember Garrett (714)
NEWS RELEASE CONTACTS: Investors: Lisa DeFrancesco (862) 261-7152 Media: Mark Marmur (862) 261-7558 Ember Garrett (714) 246-3525 JUVÉDERM VOLBELLA XC APPROVED BY U.S. FDA FOR USE IN LIPS AND PERIORAL RHYTIDS
More informationINFORMED CONSENT Juvederm INJECTION
INSTRUCTIONS This is an informed-consent document which has been prepared to help Dr. Jennifer Geoghegan inform you concerning Juvederm (Non-Animal Stabilized Hyaluronic Acid, Allergan Aesthetics) tissue
More informationEXTON - KING OF PRUSSIA SKIN (7546)
EXTON - KING OF PRUSSIA 610-518-SKIN (7546) www.drgambhir.com BODY LIPOSCULPT BY Couture UTILIZING VASER/SMART LIPOSUCTION UPPER AND LOWER ABDOMEN $4000-$6000 BACK $2000-$2500 BREASTS MALE $2000-$3000
More informationThe Authoritative Source Current US Statistics on Cosmetic Surgery. Expanded data for 2007: Multi-year comparisons, 39 Cosmetic Procedures
2 0 0 7 The American Society for Aesthetic Plastic Surgery The Authoritative Source Current US Statistics on Cosmetic Surgery 1997-2007 Cosmetic Surgery National Data Bank Statistics Expanded data for
More informationREAD THIS FOR SAFE AND EFFECTIVE USE OF YOUR MEDICINE PATIENT MEDICATION INFORMATION. TRAVATAN Z Travoprost Ophthalmic Solution
READ THIS FOR SAFE AND EFFECTIVE USE OF YOUR MEDICINE PATIENT MEDICATION INFORMATION Pr TRAVATAN Z Travoprost Ophthalmic Solution Read this carefully before you start taking TRAVATAN Z and each time you
More informationINFORMED CONSENT SOFT TISSUE FILLER INJECTION
INSTRUCTIONS This informed-consent document has been prepared to help inform you about Hylaform (animal-origin, stabilized hyaluronic acid, INAMED) tissue-filler injection therapy Restylane (Non-Animal
More informationDermal Fillers & Line Relaxing Injections. Pre Procedure & Aftercare Advice
FINOLAS AESTHETIC CLINIC AT MEDI SPA & BEAUTY CLINIC 246 Farnborough Road, Farnborough, Hampshire GU14 7JW Phone 01252 459000 / 07872 119593 www.finolasmedispaandbeautyclinic.com www.finolasaestheticclinic.com
More informationth annual COSMETIC SURGERY NATIONAL DATA BANK STATISTICS The American Society for Aesthetic Plastic Surgery
15 th annual COSMETIC SURGERY NATIONAL DATA BANK STATISTICS The Authoritative Source for Current US Statistics on Cosmetic Surgery Expanded data for 2011: Multi-year comparisons, 35 Cosmetic Procedures
More informationPLATELET RICH PLASMA (PRP) Informed Consent
PLATELET RICH PLASMA (PRP) Informed Consent Platelet Rich Plasma, also known as "PRP" is an injection treatment whereby a person s own blood is used. A fraction of blood (20cc) is drawn up from the individual
More informationFillers- Post Treatment Information
Fillers- Post Treatment Information Filler injections are a non-surgical procedure used to temporarily restore facial volume and help diminish folds and concavities. Common fillers used in our practice
More informationVICKI HENKE MICROBLADING PERMANENT COSMETICS. What to expect in the healing process for all brow enhancement/permanent makeup procedures.
MICROBLADING/MANUAL PERMANENT MAKEUP TREATMENT BEFORE & AFTER CARE INSTURCTIONS What to expect in the healing process for all brow enhancement/permanent makeup procedures. WHILE YOUR SKIN HEALS, BE PREPARED
More informationInformed Consent Injectable Fillers
Informed Consent Injectable Fillers INSTRUCTIONS This is an informed-consent document which has been prepared to help your plastic surgeon inform you concerning Juvederm & Juvederm Ultra Plus with Lidocaine
More informationstatistics Cosmetic Surgery National Data Bank The American Society for Aesthetic Plastic Surgery
2013 Cosmetic Surgery National Data Bank statistics z The Authoritative Source for Current US Statistics on Cosmetic Surgery z Expanded data for 2013: Multi-year comparisons, 35 Cosmetic Procedures z Multi-specialty
More informationBODY SWEAT REDUCTION MIRADRY $1, treatments BOTOX FOR EXCESSIVE SWEATING PER UNIT $9.95/unit units, every 3-4 months
EXTON - KING OF PRUSSIA 610-518-SKIN (7546) www.drgambhir.com PROMOTIONAL PRICING BODY SWEAT REDUCTION MIRADRY $1,950.00 1-2 treatments BOTOX FOR EXCESSIVE SWEATING PER UNIT $9.95/unit 60-120 units, every
More informationPre Treatment Advice and Procedures
Pre Treatment Advice and Procedures 1. Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear crusty for up
More informationApril Have you been thinking about getting breast implants? Now is the time to take action. Why? Two reasons:
April 2013 Jason B. Lichten, M.D., FACS ==================== Have you been thinking about getting breast implants? Now is the time to take action. Why? Two reasons: Summer it s almost here, and there s
More informationARE YOU? PsA TREAT YOUR SYMPTOMS WITH FOUR DOSES A YEAR. RECOGNIZE THE FOUR SIGNS OF PsA.
PsA STELARA is a prescription medicine approved to treat adults 18 years and older with active psoriatic arthritis (PsA), either alone or with methotrexate. WHICH YOU ARE YOU? RECOGNIZE THE FOUR SIGNS
More informationNEW PATIENT FORM. Full Name: Date of Birth Age : (First) (Middle) (Last) Address: (Street) (City) (State) (Zip code) Home #: ( ) Work Number : ( )
Office Use Only: Booker Mailchimp Referral Driver s License NEW PATIENT FORM Today s Date: Reason(s) for Today s Visit: Full Name: Date of Birth Age : (First) (Middle) (Last) Address: (Street) (City) (State)
More informationInformed Consent Hyaluronic Acid Filler Injection
Informed Consent Hyaluronic Acid Filler Injection INSTRUCTIONS This is an informed-consent document which has been prepared to help inform you about hyaluronic acidbased (non-animal stabilized) tissue
More informationStatistics. The American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank
The American Society for Aesthetic Plastic Surgery The Authoritative Source Current US Statistics on Cosmetic Surgery Expanded data for 2006: Ten year comparisons, 34 Cosmetic Procedures Multi-specialty
More informationClient Medical History Form
Client Medical History Form Today s Date: Birthday: / / Age Name: TXID# Address: Phone: Email: Tattoo Area: Eye Brows (Micro-Blading) Brand of Ink: Bio Touch Pure / / / Emergency Contact: Phone: Do you
More informationNew Patient Registration
New Patient Registration Today s Date: Social Security Number: Name: Last First MIddle How do you like to be addressed: Date of Birth: Address: Street City State Zip Email Address: Preferred Contact Number:
More informationMarch 2013 ==================== Jason B. Lichten, M.D., FACS
March 2013 Jason B. Lichten, M.D., FACS I hope you're giving your complexion lots of TLC before and after your treatments here at our office. A key element in that care is using excellent topical lotions.
More informationSTELARA INJECTION. What is in this leaflet. Before you use STELARA. What STELARA is used for. Consumer Medicine Information
STELARA INJECTION Ustekinumab (rmc) Consumer Medicine Information What is in this leaflet This leaflet answers some common questions about STELARA (pronounced stel-ahr-uh). It does not contain all the
More informationEast Hill Medical Group
Name: of Birth: Address: City: State: Zip: Home Tel. #: Cell #: Employer: Occupation: Emergency Contact: Relationship: Phone: Email: How Referred: Parents Ethnic Background: Previous Treatments Year: Area(s):
More informationClient Medical History Form
Client Medical History Form Date Birth Date Age DL or ID# Name: Address City State Zip Phone Email Emergency contact person Phone Do you presently have or previously had any of the following: (Circle yes
More informationFACT SHEET: ISOTRETINOIN INFORMATION FOR PATIENTS
FACT SHEET: ISOTRETINOIN INFORMATION FOR PATIENTS You have been prescribed isotretinoin (=Roaccutane, Oratane) for your acne. It is used for acne which does not respond to other treatments, scarring and
More informationNote : Revision case: Plus 5,000 Bahts / procedure. PPSI : NEW AESTHETIC CENTER PACKAGE PRICE LIST Price Operation Hospital Total stay in
PPSI : NEW AESTHETIC CENTER PACKAGE PRICE LIST Price Operation Hospital Total stay in Anesthesia Procedure Baht Time(Hrs) Night(s) Phuket (Days) Face / Neck Lift (Rhytidectomy) Endoscopic Forehead Lift
More informationAREA OF BODY TATTOO IS SITUATED?
CLIENT CONSULTATION LASER TATTOO REMOVAL FORM Address: Date of Birth: Suburb: State: Postcode: Telephone: Work: Mobile Home: Other: Email Address: How did you hear about us? Tattoo Removal Colours in tattoo
More informationAesthetic Patient Form
Aesthetic Patient Form Name: Date: Address: City: State: Zip: Home Phone: Work Phone: Cell: Age: Date of Birth: Occupation: Email: FITZPATRICK CLASSIFICATION SYSTEM: Please select the skin type that seems
More informationIPL CONSULTATION AND LIABILITY DOCUMENTATION
Name...... Address:... Date of Birth:... Suburb:... Postcode:... Home Phone:... Mobile:... Email Address:... How did you hear about us?... Contact in case of emergency:... Place a tick in the areas of
More informationBeauty is the signature of your life
Beauty is the signature of your life GOOD APPEARENCE LEAVES GOOD IMPRESSIONS. Medipol University Hospital Plastic Surgery Team is ready to help you to make your dreams come true with precise retouch to
More information