1414 NW Northrup, Ste 600 Portland, Oregon Cosmetic Welcome Kit

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Laureen Dennis
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1 1414 NW Northrup, Ste 600 Portland, Oregon ph: Cosmetic Welcome Kit

2 1414 NW Northrup, Ste 600 Portland, Oregon ph: fx: HEALTH QUESTIONNAIRE Name Birthdate Preferred nickname, if any How did you hear about us? Referring Physician Other referral Primary Care Provider Phone Preferred Pharmacy Phone YOU AUTHORIZE US TO LEAVE VOIC ? Yes No PREFERRED MESSAGE PHONE# Your authorized contact(s) name Phone Your authorized contact(s) name Phone Reason for Visit All Current Medications and Dosage: Please use separate page if needed Are you allergic to any medications (include latex and anesthetics)? Yes No If yes, list Do you take blood thinner, Aspirin, anti-inflammatory (e.g. ibuprofen, Motrin, Advil), Vit E? Yes No If yes, list Do you take antibiotics before dental procedures? Yes No If yes, what antibiotic: Are you prone to or have any of the following? YES NO EXPLAIN Diabetes Pacemaker/Defibrillator High blood pressure Artificial valve Heart disease Bleeding tendency Artificial joint Hepatitis or liver disease Kidney disease Eye problems Keloids/abnormal healing HIV or other immunodeficiency Organ transplantation Nerve damage or stroke Breathing problems (asthma/emphysema) Emotional disorders Cold Sores -PLEASE COMPLETE BOTH SIDES- pdcahq 01/12

3 Please list any other significant skin and medical problems Occupation Do you smoke? Do you drink alcohol? Are you pregnant or breastfeeding? Have you had a skin cancer? Yes How many packs/day? Yes How much? Yes Yes If yes, type (basal cell carcinoma, squamous cell carcinoma, melanoma), treatment and date: Do you have a family history of melanoma? Have you had Mohs surgery before? Yes Yes If yes, site of surgery and surgeon: Have you been diagnosed with cancer other than skin? Yes If yes, type, date & treatment: Have you had surgeries in the past? Yes If yes, type and date: Cosmetic Consultation: Please list previous cosmetic procedures (Laser, Botox, Fillers, and Surgeries) Additional Comments: Patient signature Date Reviewed by/date

4 NW 12th Ave. NW 13th Ave. NW 14th Ave. NW 15th Ave. NW 16th Ave NW Northrup, Ste 600 Portland, Oregon ph: Portland Dermatology Clinic, LLP is located in the Machine Works Building, look for the building with the big red stripe! Parking is available on the 5th floor in the parking garage. Enter building s parking garage on 15th and Northrup (between Northrup and Marshall). DRIVING DIRECTIONS From the North via I-5: Take Exit 302A toward city center. Turn slight right onto Broadway. N. Broadway becomes Broadway Bridge. Turn right onto NW Lovejoy St. Take 2nd right onto NW 10th Ave. Take 2nd left onto NW Northrup St NW Northrup St. is on the left. Turn left on 15th, then left into parking garage. Park on the 5th floor and take the elevator up to the clinic on the 6th floor. From the East via I-84 Merge onto I-5 N/US-30W toward Seattle. Take Exit 302A toward Rose Quarter/Broadway-Weidler St. Off ramp becomes NE Victoria Ave.,continue straight Turn left onto NE Broadway NE Broadway becomes Broadway Bridge. Turn right onto NW Lovejoy St. Take 2nd right onto NW 10th Ave. Take 2nd left onto NW Northrup St NW Northrup St. is on the left. Turn left on 15th, then left into parking garage. Park on the 5th floor and take the elevator up to the clinic on the 6th floor. From the West via Hwy 26 From the South via I-5: Merge onto I-405 N via Exit 299B on the left, toward US-26 W/City Center/Beaverton. Take Exit 2B toward Everett St. This exit turns into NW 14th Ave. Take left onto NW Northrup St NW Northrup St. is on the left Turn left on 15th, turn left into parking garage. Park on the 5th floor and take the elevator up to the clinic on the 6th floor. From the West via Hwy 30 (St. Helens): Take Hwy 30 towards SE Santosh St. Keep right at the fork, follow signs for I-405 S/ US 26/ Salem and merge onto I-405 S Take Exit 2B towards Everett St. Merge onto NW 16th Ave. Turn left onto NW Everett St. Take the 2nd left onto NW 14th. Take left onto NW Northrup St NW Northrup St. is on the left Turn left on 15th, turn left into parking garage Park on the 5th floor and take the elevator up to the clinic on the 6th floor. 30 Merge onto I-405 via exit on the left towards St. Helens/Seattle Take Exit 2B - Everett St. Follow the rest of the directions from the South via I-5 Lovejoy St. Burnside St. Portland Dermatology Clinic Pearl 5 84 NW Pettygrove St. 405 NW Overton St. NW Northrup NW Marshall St. 405 Portland Dermatology Clinic LLP NW Lovejoy St. NW Kearney St. NW Johnson St. Oregon Health Sciences University 26

5 skin care services SKIN CARE EVALUATION Non-patients $ 50 Patients Complimentary CHEMICAL PEELS Chemical peels are a proven, safe method of exfoliation, removing cellular build-up on the surface layers of your skin. Peels are useful for acne, prematurely aged skin due to sun exposure, rosacea, hyperpigmentation, acne lesions and dry skin. We offer a range of peels - from light to stronger. CHEMICAL PEELS PRICING Sensi Peel Exfoliating Treatment $ 75 Skin Ceuticals Micropeel 20% or 30% $ 100 Skin Ceuticals Micropeel Plus 20% or 30% $ 125 PCA Enhanced Jessner Peel $ 100 PCA Ultra Peel $ 100 PEEL SERIES Peel treatments are available individually or in a series of 6 to ensure the greatest benefits. Purchase a peel series package and get 6 peels for the price of 5! $75.00 Peel Package $ 375 $ Peel Package $ 500 $ Peel Package $ 625 PEELS AND MORE... We may recommend pore extractions to clear breakouts and open clogged follicles as a separate treatment offered with or without a peel. A slush is a refreshing, soothing cryotherapy treatment for acne. ADDITIONAL SERVICES PRICING Extractions $ 75 Extractions added to a Peel $ 50 Neck & Chest added to a Peel $ 50 Neck & Chest added to a Peel Series $ 250 Slush $ 75 COSMETIC SERVICES SKIN CARE SERVICES aesthetic, medical & laser services Dr. Ken Lee is an expert in cosmetic fillers and laser surgery, offering highly customized facial enhancement with cosmetic injectables and laser surgery. Before performing any cosmetic procedure, he carefully evaluates your skin using four objectives: pigment and vascular change; dynamic wrinkles; texture; and contour/volume loss. Dr. Lee will recommend treatments best suited to your goals and your skin s condition to leave you with a natural look. We offer an array of cosmetic treatments, including Botox & Dysport injectables and a variety of dermal fillers. We have multiple state-of-the-art lasers for intense pulsed light (IPL) photofacials, fractional laser resurfacing, and vascular (redness) treatments. Dr. Lee performs cosmetic facial injections and most of our laser treatments. Some of the laser treatments are provided by our highly trained medical staff. Pricing for your individual service is quoted at the time of consultation. Skin care services start with a complimentary skin care & products evaluation. We re here to consult with you about your skin care, to address your concerns and to suggest products and services best suited to your skin. Our skin care services include a variety of chemical peels, extractions and slushes. We offer a wide range of hypoallergenic sunscreens and skin care products carefully selected by our board-certified dermatologists for purity. During your complimentary skin care consultation, we ll recommend products best suited for your skin s condition. See the product insert of this menu for a full listing of products. Call to schedule your consultation with Dr. Lee or start with a complimentary skin care & products evaluation with our skin care medical assistant.

6 cosmetic services COSMETIC CONSULTATION WITH DR. KEN LEE New Patients $ 90 Existing Patients Complimentary BOTOX /DYSPORT Botox and Dysport are injectables that work by relaxing facial muscles to smooth the effects of aging. Treatments are 15 minutes and effects last 3-4 months. Conditions treated: Frown lines Forehead wrinkles Crow s feet around eyes Smoker s lines Sagging eyebrows BOTOX PRICING $ 15 / unit for first 20 units, then $ 10 / unit Minimum treatment charge of $ 100 DYSPORT PRICING Inquire with staff for details DERMAL FILLERS Dermal fillers offer a great way to smooth wrinkles, plump lips, and fill facial folds and hollows caused by loss of collagen. Treatments are 15 minutes and last from 6 months to 2 years. Conditions treated: Wrinkles Hollowed cheeks Nasolabial folds ( parentheses lines) Bags & dark circles under eyes Smile lines ( marionette lines) Jowls Thinning lips Indented scars DERMAL FILLERS PRICING Juvederm /Restylane / Belotero - smooth substance softens wrinkles, plumps lips, fills folds: Per syringe $700 Sculptra - long lasting, natural lift to shape facial contours: 1 vial $ 750 lasers LASER TREATMENTS INCLUDE: Photofacials Reduction of redness & vessels OUR LASERS CAN TREAT THESE CONDITIONS: Sun damage Age spots Rosacea LASERS AVAILABLE Lumenis M22 Intense Pulsed Light (IPL) - non-ablative photofacials to treat redness and aging Lumenis Ultra Pulse Fractionated CO2 - for Deep FX and Active FX ablative skin resurfacing, the ultimate laser therapy for wrinkle removal and skin tightening Candela VBeam Perfecta - vascular lesions and redness LASER SERVICES PRICING Broken blood vessels Angiomas Red birthmarks Small area (nose) $ 300 Medium area (face) $ 500 Large area (face & neck) $ 700 Extra large area (full face, neck & décolleté) $ 900 Radiesse - immediate, natural look to replenish volume: Per syringe $ 700

7 products SUNSCREEN LAROCHE-POSAY Anthelios SX SPF 15 $ 29 Anthelios 30 Spray $ 36 Anthelios 60 Spray $ 36 VANICREAM Sensitive Skin SPF 30 $ 13 Sensitive Skin SPF 60 $ 16 Sport SPF 35 $ 13 SKIN CEUTICALS Sheer Physical UV Def SPF 50 $ 34 Physical Fusion UV Def SPF 50 $ 34 Sport UV Defense SPF 45 $ 40 COLORESCIENCE Jar SPF 30 $ 28 Refill SPF 30 / SPF 50 $ 19 MD SOLAR SCIENCES Lotion SPF 40 $ 28 Gel SPF 30+ $ 24 Tinted Gel SPF 30+ $ 22 Sport Stick SPF 40 $ 12 Kids Stick SPF 41 $ 12 TILLEY ENDURABLES Tilley Hat $ Tilley Hat Kids $ 24 SENSITIVE SKIN LAROCHE-POSAY Toleriane Foaming Cream $ 24 Toleriane Dermo-Cleanser $ 24 Toleriane Facial Fluid $ 30 Toleriane Soothing Cream $ 29 Toleriane Riche $ 29 Hydraphase Eyes $ 34 ACNE & ANTI-AGING SKIN CEUTICALS LHA Cleansing Gel $ 38 LHA Solution $ 38 Blemish & Age Defense Serum $ 82 Adult Acne Kit $ 130 Clarifying Clay Mask $ 49 Micro Exfoliating Scrub $ 30 Clarifying Cleanser $ 34 Purifying Cleanser $ 34 Simply Clean $ 34 Gentle Cleanser $ 34 Conditioning Solution $ 34 Eye Cream $ 70 Eye Balm $ 81 AOX Eye Gel $ 87 A.G.E. Eye Complex $ 88 A.G.E. Interrupter $ 156 Daily Moisture $ 60 Hydrating B5 Gel $ 74 Skin Firming Lotion $ 110 Epidermal Repair $ 69 Primacy Hydra Balm $ 22 Serum 15 AOX $ 100 CE Ferulic $ 153 Phloretin CF $ 155 Phloretin CF Gel $ 155 Antioxidant Lip Repair $ 38 Phyto Corrective Gel $ 62 Retexturing Activator $ 73 Pigment Regulator $ 85 Retinol.5% $ 55 OBAGI Gentle Cleanser $ 40 Foaming Gel Cleanser $ 40 Toner $ 40 Clear $ 99 Blender $ 95 NU-DERM Eye Cream $ 58 Tretinoin Cream.025 $ 49 Tretinoin Cream.05 $ 51 Tretinoin Cream.1 $ 56 SPECIALTY PRODUCTS Aquaphor $ 2 Dr. Dan s Lip Balm $ 7 Derm Bath $ 10 Lotion Applicator $ 7 Replacement Pads $ 3 Magic Wart Cream $ 47 Triluma $ 95 CeraVe Cleanser $ 12 CeraVe Cream $ 14 Elta Tar (pump $ 20 addtl.) $ 16 Free & Clear Shampoo $ 14 Free & Clear Conditioner $ 15 Latisse $ 125 Cotton Gloves $ 2 Vanicream Lotion $ 9

8 PATIENT FINANCIAL POLICY AND SIGNATURE ON FILE Patient Name: DOB: / / Date / / Receipt of Privacy Practices: My signature below indicates that I have received and/or reviewed a copy of my physician's Notice of Uses and Disclosures of Protected Medical Information (Notice of Privacy Practices). May we you announcements and our newsletter? ( ) Yes ( ) No Patient or Responsible Party Signature Date / / FINANCIAL POLICY: Portland Dermatology Clinic (PDC) is pleased to participate in a large number of different insurance plans. While we are pleased to participate in these plans patient's individual coverage is not verified by our office staff prior to appointments. Patients should contact their insurance companies directly for any coverage questions they may have. Co-pays and deductibles usually apply to office visits and treatments performed at PDC. If the insurance company denies payment or only pays a portion of the medical bill, the patient will be responsible for payment of the remaining balance. Patients with insurance (not including Medicare): Patients are asked to bring their current insurance identification card to each appointment. If your insurance information is not received within 1 business day of your appointment, the balance incurred from your visit will be your responsibility and your insurance will not be billed. Co-payments are due at time of service. Patients are responsible for paying insurance deductibles, co-insurance, and any services not covered by insurance. For patients on insurance plans in which our doctors are not contracted, as a courtesy, we will submit a claim to your insurance company. A down payment of $217 is due at the time of service. PATIENTS SCHEDULED FOR MOHS SURGERY, please contact our billing department for payment arrangements. Any additional services will require a payment of 35% of the total bill at the time of service. Patients without insurance (Private Pay): Payment is due in full at the time of service. Please note, if you have a procedure your specimen may be sent out for tissue processing which could prompt an additional bill from our preferred laboratory. Cosmetic Procedures: Payment for any cosmetic procedure is due at time of service. Certain procedures require a prepayment to hold the appointment. This payment is kept as a deposit and will be applied to the consultation with the doctor. Agreement: I attest that the information I have provided to Portland Dermatology Clinic is correct and true to the best of my knowledge. I hereby assign benefits to Portland Dermatology Clinic, LLP, and authorize them to furnish information regarding my medical condition to my insurance carrier. I understand that I am responsible for any amount not paid by my insurance per the provisions of my policy. Furthermore, I understand that if payment is returned due to insufficient funds or my account is turned to a collection agency for non-payment, a $25 fee will be assessed. I have read and understand the financial policy and my signature below indicates I accept this policy and agree to abide by the terms for my treatment at the Portland Dermatology Clinic. Patient or Responsible Party Signature Date / / *MEDICARE PATIENTS SEE REVERSE SIDE*

9 Medicare Subscribers Medicare Payment Policy: We are participating providers of the Medicare program. We will accept assignment on all claims. Patients are responsible for meeting their annual $ deductible and paying for the 20% copayment. We do file with secondary / supplemental carriers. However, in the event that the secondary does not pay within 60 days, patients will be balanced billed. Please sign so we may have your Medicare Authorization on file: I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier any information needed for this or a related Medicare Claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits applies. Signature: Date: / / Please sign so we may have your Supplemental Authorization on file: I request authorized MEDIGAP benefits be made on my behalf for any services furnished to me. I authorize any holder of medical information to release to the above MEDIGAP carrier any information needed to determine these benefits or the benefits payable for related services. Signature: Date: / / Note: If you have recently joined (or changed) to a Medicare Advantage plan, please let our staff know so we can update your records and advise you if we are participating providers. Please present Medicare and secondary insurance card(s) and a photo ID to the receptionist so copies may be made.

10 Notice of Your Right to Decide Participation in Future Anonymous or Coded Genetic Research The State of Oregon has laws to protect the genetic privacy of individuals. These laws give you the right to decline to have your health information or biological samples used for research. A biological sample may include a blood sample, urine sample, or other materials collected from your body. You can decide whether to allow your health information or biological samples to be available for genetic research. Your decision will not affect the care you receive from your health care provider or your health insurance coverage. Research is important because it gives us valuable information on how to improve health, such as ways to prevent or improve treatment for heart disease, diabetes, and cancer. Under Oregon law, a special team reviews all genetic research before it begins. This team makes sure that the benefits of the research are greater than any risks to participants. In anonymous research, personal information that could be used to identify you, like your name or medical record number, cannot be linked to your health information or biological sample. In coded research, personal information that could be used to identify you is kept separate from your health information or biological sample so it would be very difficult for someone to link your personal information to your health information or biological sample. Your identity is protected in both types of research. If you want to allow your health information and biological sample to be available for anonymous or coded genetic research, please check the box below. If you make this choice, your health information or biological sample may be used for anonymous or coded genetic research without further notice to you. If you want to decline to have your health information and biological sample available for anonymous or coded genetic research, you must complete this form and submit it to your health care provider. Your decision is effective on the date your health care provider receives this form. If you have any questions or concerns about this notice, please contact Cathy Palin at: (503) No matter what you decide now, you can always change your mind later. If you change your mind, tell your health care provider your decision in writing by sending a letter to: Portland Dermatology Clinic, LLP 1414 NW Northrup Ste 600 Portland, OR If you change your mind, the new decision will apply only to health information or biological samples collected after your health care provider receives written notice of your new decision. I decline to have my health information and biological samples available for anonymous or coded genetic research. I understand that my health information and biological samples are available for anonymous or coded genetic research. Printed Name / / Date of Birth Signature / / Today s Date

Patient Information. M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Whom may we thank for referring you?

Patient 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: