To ensure both the effectiveness and the safety of your treatment, please complete this health history as accurately as you can.
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1 Vascular and Endvascular Institute f MI, P.C. Medispa Garfield Rad, Suite 112 Clintn Twnship, MI Phne: Fax: W W W. M Y V E I M. N E T T ensure bth the effectiveness and the safety f yur treatment, please cmplete this health histry as accurately as yu can. PERSONAL INFORMATION Last Name: First Name: DOB: Gender: Female Male Address: Apt #: City: State: Zip Cde: Mbile: Hme: Wrk: Cntact me abut special PROMOTIONS, OFFERS, NEWS and FREE GIVE AWAYS. I AM INTERESTED IN: (Please check all that apply) LASER HAIR REMOVAL SKIN REJUVENATION SKIN CARE ADVICE / PRODUCTS SKIN TIGHTENING ACNE SCAR TREATMENT PIGMENTED LESIONS ROSACEA TREATMENT SUN DAMAGE / AGE SPOTS FACIAL VEIN TREATMENTS ACNE TREATMENTS LASER LEG VEIN TREATMENTS WRINKLE TREATMENTS PHOTOFACIAL SCLEROTHERAPY VARICOSE VEIN TREATMENT OTHER, PLEASE SPECIFY: DO YOU USE SUNSCREEN: IF, SPF # AND BRAND: WHEN YOU SUNBATHE, HOW DOES YOUR SKIN RESPOND? ALWAYS BURN, NEVER TAN USUALLY BURN, TAN WITH DIFFICULTY SOMETIMES BURN, TAN ABOUT AVERAGE ALMOST NEVER BURN, TAN VERY EASILY RARELY BURN, TAN EASILY NEVER BURN, ALWAYS TAN MEDICAL HISTORY (Please circle yur answer) ACCUTANE ACNE HEPATITIS HIRSUTISM ALLERGIES (drug r latex) HIGH BLOOD PRESSURE ARTHRITIS HIV POSITIVE AUTOIMMUNE DISORDER KELOID SCARS (ther scars) BLOOD DISORDERS KIDNEY DISEASE CANCER (radiatin therapy) METAL PINS IN BODY COLD SORES MELAMA CONTACT LENSES PACEMAKER DERMATITIS/ECZEMA RETIN A DIABETES PCOS (plycystic varian) EPILEPSY SKIN PIGMENTATION GENETIAL HERPES STD HORMONAL IMBALANCE Sterid r Hrmnal Therapy HEART CONDITION SHINGLES HEMOPHILIA VITILIGO 1
2 PATIENT QUESTIONNAIRE Which f the fllwing best describes yur skin type? (Please circle the ne that best describes yur skin type) I Always burns, never tans IV Rarely burns, always tans II Always burns, smetimes tans V Brwn, mderately pigmented skin III Smetimes burns, always tans VI Black skin What is yur eye clr? What is yur hair clr? What is yur race? What is yur skin clr (nn-expsed areas)? Reddish Very Pale Beige Tint Light Brwn Dark Brwn When did yu last expse yurself t the sun r sunlamp/bed? days/weeks/mnths Have yu undergne any f the fllwing hair remval methds r csmetic treatments in the past six weeks? Waxing Electrlysis Tweezing Depilatries Btx/cllagen injectins Chemical Peeling D yu use any skin care prducts that cntain Retin-A, alpha/beta hydrxy acids, r glyclic acid? Yes N If s, what was the last date f their use? Have yu ever had laser hair remval? Yes N Have yu ever used ACCUTANE? Yes N If yes, when did yu last use it? Are yu taking any f the fllwing medicatins? Tetracyclines Tetracycline, Dxycycline Diuretics Lasix, Thiazide/HCTZ Diabetics/Sulfnylureas Glipizide, Glyburide Sulfa Sulfamethxazle, Bactrim, Septra NSAID s Aleve/Naprsyn/Naprxen Grisefulvin D yu have a histry f any abnrmal r kelid scarring? Yes N D yu have a histry f herpes r cld sres/fever blisters? Yes N D yu have Lupus? Yes N D yu have either Epilepsy r a seizure disrder? Yes N D yu have any dental wrk like fillings, bridges and/r crwns? Yes N D yu have any csmetic r prfessinal tatts? Yes N If s, where? Are yu pregnant? Yes N If nt peri- r pst-menpausal, what is the date f yur last menstrual perid? Have yu ever had a bld hrmne wrk-up? Yes N D yu have PCOS (Plycystic Ovarian Syndrme)? Yes N Any knwn Endcrine prblems? Yes N D yu have any significant medical prblems? Yes N If s, what? I certify that the preceding medical, persnal and skin histry statements are true and crrect. I am aware that it is my respnsibility t infrm the technician, aesthetician, physician, physician assistant, r nurse f my current medical r health cnditins and t update this histry as a current medical histry is essential fr the caregiver t execute apprpriate treatment prcedures. Signature: Date: 2
3 LASER TREATMENT PATIENT EVALUATION This infrmatin will help ur ffice t better evaluate yur skin type s the laser treatment will be mre effective. By using the infrmatin yu prvide n this frm, we can be better prepared t prvide yu with the best care. Please take a few minutes t fill ut this questinnaire by circling the crrect answer under the number. Skin type is determined genetically and is ne f the many aspects f yur verall appearance, which als includes the clr f yur eyes, hair, etc. The way yur skin respnds t sun expsure is anther way f crrectly assessing yur skin type. Recent tanning, whether by the sun r an artificial tanning bth, even tanning creams, can have a majr impact n yur skin clr evaluatin. Genetic Dispsitin Scre Yur natural eye clr? Light Blue, Green, r Gray Blue, Gray r Green Blue Light Brwn/Dark Brwn Black Natural clr f yur hair? Sandy, Red Blnde Chestnut/Dark Blnde Dark Brwn Black Clr f yur nn- expsed skin? Reddish Very Pale Pale with beige tint Light Brwn Dark Brwn D yu have freckles n unexpsed areas? Many Several Few Incidental Nne Ttal scre fr genetic dispsitin: Reactin t Sun Expsure Scre What happens when yu stay t lng in the sun? Painful redness, blistering, peeling Blistering, fllwed by peeling Burns smetimes, fllwed by peeling Rarely burn Never burn T what degree d yu turn brwn? D yu turn brwn within several hurs after sun expsure? Hardly r nt at all Light clr tan Reasnable tan Tan every easy Turn dark brwn quickly Never Seldm Smetimes Often Always Hw des yur face react t the sun? Very sensitive Sensitive Nrmal Very resistant Never had a prblem Ttal scre fr reactin t sun expsure: Tanning Habits Scre When did yu last expse yur bdy t sun r tanning bth/cream? D yu expse the area t be treated t the sun? Mre than 3 mnths ag Never 2-3 mnths ag Hardly ever 1-2 mnths ag Less than ne mnth ag Less than 2 weeks ag Smetimes Often Always Ttal scre fr tanning habits: Summary Add up the ttal scres fr each sectin fr yur Skin Type Scre t give yu a better evaluatin f yur skin type. Ttal Scre fr Skin Type Skin Type Scre Fitzpatrick Skin Type 0-7 I 8-16 II III IV Over 30 V - VI Patient Signature: Date: 3
4 Vascular and Endvascular Institute f Michigan P.C. I hereby authrize and direct any assciates r assistants f Vascular and Endvascular Institute f MI, P.C. (Patient Name) t perfrm treatment n me. (Type f Treatment) I understand that the GentleMax Pr frm Candela is a device used fr hair remval, skin rejuvenatin, acne treatment, wrinkle reductin, and skin tightening, f which I am cnsenting t be a patient receiving the treatment stated abve. I specifically acknwledge that n guarantees r warranties have been made cncerning the results f the prcedure. The fllwing pints have been discussed with me and I understand: Eye prtectin must be wrn at all times during the treatment. I understand that the purchase f a package des nt ensure that I will nt need additinal treatments. I am fully aware that my cnditin is f csmetic cncern and that the decisin t prceed is based slely n my expressed desire t d s. I cnfirm that I am nt pregnant at this time. I acknwledge that it is my respnsibility t let my technician knw if I becme pregnant during treatment. I d nt have a pacemaker r internal defibrillatr. I have nt taken Accutane within the last 6 mnths. Clse adherence t ideal laser schedules will imprve yur results. Cnversely, failure t fllw the laser schedule may diminish yur results and in turn require mre treatments than nrmal. I hereby authrize Vascular and Endvascular Institute f MI, P.C. r any assciates t take pictures f the treated area t be used in my patient file as well as annymus use fr the purpse f educatin and prmtin. I understand that immediately fllwing the laser treatment, the treated area will appear as a red disclratin and have edema (swelling). The redness (erythema) and disclratin may take up t 6 mnths t heal. The treated area will feel like a sunburn fr a few hurs after the treatment. I have received a cpy f the pre and pst laser treatment dcument. Aftercare guidelines are crucial fr healing, preventin f scarring and hyperpigmentatin. I certify that I have been given the pprtunity t ask questins and that I have read and fully understand the cntents f this cnsent frm. ACKWLEDGE I understand that I release Vascular and Endvascular Institute f MI, P.C. and its assciates, the Medical Directr, the laser technician perfrming services, and any ther persn invlved in my treatment frm any liability assciated with cmplicatins frm the laser prcedure. I understand that all prcedures are priced per treatment. I understand that n guarantees can be made and all payments are nn-refundable. By my signature belw, I certify that I have read and fully understand the cntents f this permissin and authrize the perfrmance f my treatment with the GentleMax Pr by the staff f Vascular and Endvascular Institute f MI, P.C. Patient Signature: Date: Witness Signature: Date: 4
5 Vascular and Endvascular Institute f Michigan P.C GARFIELD ROAD SUITE 112 CLINTON TOWNSHIP MI, Phne Fax WRITTEN FINANCIAL POLICY Thank yu fr chsing Vascular and Endvascular Institute f Michigan P.C. Our primary missin is t deliver the best and mst cmprehensive care available. An imprtant part f the missin is making the cst f ptimal care as easy and manageable fr ur patients as pssible by ffering several payment ptins. Payment Optins: Yu can chse frm: Please nte: - Cash, Check, Visa, MasterCard, Care Credit, r Discver Card We ffer a 5% curtesy accunting adjustment t patients wh pay in full fr their treatment with cash prir t the beginning f any treatment fr treatment plans f $1,000 r mre. - INTEREST Payment Plans frm Care Credit Allws yu t make payments with INTEREST Cnvenient, lw mnthly payment plans available N annual fees r pre-payment penalties Must be paid in full within the prmtinal perid Vascular and Endvascular Institute f Michigan P.C. requires payment fr all treatments due at the time f the treatment. Fr prmtinal packages r gruped treatments, payment fr the entire package is due prir t the first scheduled treatment. All sales are final and nn-refundable. Vascular and Endvascular Institute f Michigan P.C. charges $35.00 fr returned checks. All Service packages and pre-paid treatments (except Laser Hair remval) must be used within 12 mnths f date f purchase r they will expire. Laser Hair Remval must be used within 18 mnths f date f purchase r they will expire. If yu have any questins, please d nt hesitate t ask. We are here t help yu get the quality care yu deserve. Patient Name (Please Print) Date Patient r Guardian Signature * If paid within the prmtinal perid. Otherwise, interest assessed frm purchase date. Minimum mnthly payment required. ** Subject t credit apprval *** Hwever, if we d nt receive payment frm yur insurance carrier within 30 days, yu will be respnsible fr payment f yur treatment fees and cllectin f yur benefits directly frm yur insurance carrier. 5
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