5504 Backlick Road Springfield, Virginia
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- Barnard Oliver
- 5 years ago
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1 Name: Address: Phone: City: Zip Code: Cell: Phone: Text Cell Phone How did you hear about us: General Health State: Contact me by 1. Rate your level of stress: (5 = highest, 1= lowest) Are you pregnant or nursing? Yes No 3. Do you wear contact lenses? Yes No Occupation: Date of Birth: Emergency Contact: Referral Name: 4. Do you smoke? Yes No How many cigarettes per day? Drink? Yes No # of drinks per week 5. Please list any accidents or surgeries in the last 9 months: 6. Do you have any metal implants, a pacemaker or body piercings? 7. List the medications you are currently taking: Prescription Over the Counter Health History Heart Condition Lymph Edema Herpes/Shingles High Blood Pressure Low Blood Pressure Numbness/Tingling Sinus Problems Allergies Chronic Pain Varicose Veins Rashes Jaw Pain/TMJ Blood Clots Constipation Sprains/Strains Diabetes Gas/Bloating Headaches Arthritis Spasms/Cramps Broken/Fractured Bones Pregnancy ( weeks) Fatigue/Sleep Disorder Depression/Anxiety Cancer
2 Other (explain): Undergoing Cancer treatment SkIn Care 1. Are you under the care of a dermatologist? Yes No 2. Do you use: Accutane Retin A Renova Adapalene Other prescription skin products 3. Have you had a: Chemical Peel Microdermabrasion Botox Other resurfacing treatments 4. Are you currently using any products that contain: Glycolic Acid Lactic Acid Hydroxy Acid Vitamin A 5. Do you have any skin sensitivities or irritants SkIn MaIntenance Products You Use: Soap Cleanser Toner Moisturizer Exfoliator Masque Sunscreen UVA UVB SPF Other: Skin Type: Oily/Congested Dry/Dehydrated Sensitive/Redness Acne Sunburned Do you have any of these conditions? Rosacea Acne Shingles HIV Herpes Eczema Claustrophobia Psoriasis Iodine or Shellfish Have you been tanning, used spray tan or self tanner in the last 24 hours? Yes No Are you going or coming from a vacation? Yes No What are your skin care goals? It is my choice to receive these Services from Furst MD Aesthetics. I have completed this form to the best of my knowledge. I have stated all medical conditions that I am aware of and I will update the staff Furst MD Aesthetics of any changes to my health status. If I am unable to make a scheduled appointment, I agree to cancel the appointment 24 hours in advance by phone, unless I have an emergency. In this case I will call ASAP to reschedule my appointment. If I miss a scheduled appointment without giving 24hour notice, I agree to pay the missed appointment fee that applies.
3 Name Date
4 CLIENT TREATMENT NOTES Client: Chart # Treatment Notes: Treatment Notes: Treatment Notes: LASER/LIGHT TREATMENT SHEET
5 Date of Service Area of Treatment Hand Piece Setting MS Setting Notes Clinician j/c 2 PATIENT: CHART# CONSENT FOR LASER/LIGHT BASED TREATMENT I authorize Eric Furst MD and the dedicated staff at Furst MD Aesthetics to perform laser/ pulsed light cosmetic treatments on me, including but not limited to deep tissue heating,treatment of pigmented lesions, vascular lesions, acne, and/or wrinkles. I understand that the procedure is purely elective, that the results vary with each individual, and that multiple treatments may be necessary.
6 I understand that: Serious complications are rare, but possible. Common side effects include temporary redness and mild "sunburn" like effects that may last a few hours to 3-4 days or longer. Pigment changes, including hypopigmentation (lightening of the skin) or hyperpigmentation (darkening of the skin), lasting 1-6 months or longer may occur. In addition, freckles may temporarily or permanently disappear in treated areas. Other potential risks include crusting, itching, pain, bruising, burns, infection, scabbing, scarring, swelling, and failure to achieve the desired result. Lasers/intense light can cause eye injury and protective eyewear must be worn during treatment. I understand that a series of treatments may be required to achieve the desired result. I understand that sun or tanning lamp exposure and not adhering to the post-care instructions provided to me may increase my chance of complications. I consent to photographs being taken to evaluate treatment effectiveness, for medical education, training, professional publications or sales purposes. Photographs revealing my identity will not be used without my written consent. If my identity is not revealed, these photographs may be used and displayed publicly without my permission. Before and after treatment instructions have been discussed with me. The procedure as well as the potential benefits and risks have been explained to my satisfaction. I have had all my questions answered. I freely consent to the proposed treatment. Patient's Signature: Print Name: Witness Signature: Print Name: Initial Here and date each treatment. #2 #3 #4 #5 #6 Cosmetic Procedure Contract I,, agree to the treatment plan and fees regarding the following laser/light source procedure(s) discussed with me by the staff at Furst MD Aesthetics Signing this contract does not obligate me to have this procedure(s) performed. It is designed to inform me of the costs of the procedure(s) and the policies involved in cancellation and payment. The following fees have been quoted and are expected at time of treatment: Procedure(s): Treatments Required: spaced weeks apart. Cost per Treatment: $ These fees are guaranteed until I understand and accept the following financial arrangement:
7 The entire cost of each procedure is to be paid in full at the time of service. This may be paid by cash, pre- approved check, MasterCard/VISA or Care Credit or divided between any of these payment methods. Elective cosmetic procedures are not covered by insurance. Reservation Policy: We understand that life is busy and emergencies arise and we will understand missing one appointment, however, should a client miss an appointment or cancel a procedure less than one (1) business day prior to the scheduled time a second time, a cancellation fee of $50.00 may be charged. Thank you for visiting Furst MD Aesthetics. Client Signature Date Witness Signature Date
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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
LASER TREATMENT INFORMED CONSENT
LASER TREATMENT INFORMED CONSENT PRINT NAME: BIRTHDATE: / / DATE: The following Larson Modality Services are performed by trained, certified, licensed personnel and healthcare providers of Margaret L.
CLINICAL FORMS AND CHARTING
CLINICAL FORMS AND CHARTING CLINICAL Lira Clinical forms to help you chart, analyze and evaluate your client for a successful skin care plan. 110 110 NAME TREAMENT DATE PROFESSIONAL RESURFACING TREATMENT
Menter Cosmetic Institute 3900 Junius Street, Suite 105 by Texas Dermatology Associates Dallas TX, (972) Ext. 255
PRECAUTIONS TO CONSIDER BEFORE FRAXEL TREATMENTS SIX TO TWELVE MONTHS BEFORE TREATMENT: Stop use of Accutane TWO WEEKS BEFORE TREATMENT: Stop use of all Retinols - Retin-A, Tazorac, anti-aging products