The Aesthetic and Wellness Center, PLC
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- Simon Turner
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1 Dear DealSaver Member: Welcome to The Aesthetic and Wellness Center. You have taken advantage of a great bargain. We hope you have a wonderful experience with us and you are satisfied with the results of your treatments. Microdermabrasion uses fine aluminum oxide crystals to exfoliate aging or sun damaged skin. It also stimulates the rebuilding of collagen and skin cell growth, returning firmness and a healthy glow to your skin. The combination of Microdermabrasion with a hydration treatment will beautify your facial skin, making it softer and smoother. Your services will be provided by Clara Diaz our licensed medical aesthetician. Microdermabrasion: improves coarse and dry skin reduces fine lines and wrinkles improves acne and surgical scars unclogs pores and minimizes blackheads hyperpigmentation and sun damaged skin For optimal results we recommended a series of treatments. The number of treatments needed will depend on your skin type and condition. If you would like to upgrade your offer, we have packaged a series of additional skin cares services that will enhance the result of your treatments. To schedule your appointment call us at We require 24 hour cancellation or a $25 fee will be applied. To prepare for your first treatment, visit our website Click on the tab client resources, look for the tab office forms, then print and complete these forms: Dealsaver- Microdermabrasion + Hydration package and HIPPA Privacy Policy. Please bring these forms with you on your first visit. If you have any problems downloading these forms, we will be happy to or fax them to you. We look forward to seeing you, Dr. Inda Mowett & staff 1
2 PATIENT INFORMATION FORM Name: (Last) (First) (M.I.) Sex: (M / F) SSN: Birth Date: Age: Home Address: City State Zip Code Home Phone: ( ) Cell Phone: ( ) Address: Best number to reach you: Alternative address: Employment Information: Employer: Occupation: Phone: ( ) ext: In Case of Emergency: Name: _Relationship Phone :( ) How did you hear about us? Magazine Physician office CitiRevealed Referral by Current Patient Sign/Location Seminar Coupon Book Gyms Television Radio advertising marketing Newsletter Facebook Website Local Spa/Salon Financial Policy: Please be advised that full payment for all services will be due at the time services are rendered. For your convenience we accept Visa, Master Card, Discover, Debit Card or Cash. We DO NOT accept personal checks. No Show or Cancelled Appointment Policy: We do not accept clients without appointments. Appointments that are not cancelled 24 hours prior to appointment time will be billed a $25.00 cancellation fee. Cancellation or no-show fees must be paid prior to making future appointments and are the sole responsibility of the client. Missed appointments cannot be credited to next week s treatment period. Lipotropic injections missed cannot be credited for future injections. If you are enrolled in a special program through your employer, cancelled or no show appointments will be applied to your treatment plan and will be charged to your treatment program. Repeat cancelled, or no-show appointments may result in termination from treatment at this practice. Cancellation Policy If you purchase a treatment package and do not complete the series, your bill will be reconciled at the individual treatment rate and any resulting credit can be applied only to a gift certificate or to additional services or products. In regards to the Weight Loss Program, if you withdraw from the program, you will not be entitled to a refund of any previously paid monies. My signature on this form confers the authorization for Medical treatment by Inda Mowett, MD and her staff at The Aesthetic & Wellness Center. Signature Date 2
3 MEDICAL HISTORY Name: Age: Birth date: Today s Date: Last Physical/Bloodwork: Primary Physician s Name: Office phone # (Primary Care Physician): What is your reason for your visit today? Cosmetic Services Weight Management Mesotherapy General Health History Autoimmune Deficiency Heart Attack Neurological Disease Eating Disorder Heart Disease Pacemaker Arthritis High Cholesterol Palpitations Asthma HIV/AIDS Psychiatric Care Bleeding Disorder Anemia Rheumatoid Fever Cancer Hypertension Skin Allergies Chemical Dependency Infection (active) Stroke Cold Sores/Fever Blisters Keloid Scar Formation Thyroid Disease Depression Kidney Disease Gout/Hyperuricemia Diabetes Liver Disease Surgery (Please list below) Emphysema/COPD Lung Disease Epilepsy/Seizures Migraine Headaches Gastric Reflux Multiple Sclerosis Allergies * Medications: * Food: * Cosmetics: * Latex/Other: * Are you allergic to: Lidocaine Beef Strawberries Eggs/ Chicken Collagen Current medications Social History Single Married Widowed Occupation: Do you smoke cigarettes? If yes, how many packs a day: Do you drink alcohol: If yes, weekly alcohol intake: 3
4 Women only: Date of last menstrual period: Are you pregnant? Are trying to get pregnant? Are you nursing? Are you currently using contraception? Are you currently on hormonal replacement? If yes, please provide name of medications: Family History: Check if any of your blood relatives have had any of the following: None Cancer Diabetes Heart Disease Stroke Kidney Disease Obesity High Blood Pressure Other: History of previous cosmetic treatments or procedures: Ablative Laser Laser Acne Treatments Botox Laser/IPL Hair Removal Cellulite Reduction Mesotherapy Chemical Peels Microdermabrasion Dermal Fillers Permanent Make-Up IPL Fotofacial Sclerotherapy Medical Pedicure Body sculpting Skin Tightening When did you have it done? Are you currently taking/using? Retin-A Renova Steroids Prescription acne medication Have you been taking Accutane for the past 12 months? What line of skin products are you using? I understand the information on this form is essential to determine my medical and cosmetic needs and the provision of treatment. I understand that if any changes occur in my medical history/health I will report it to the office as soon as possible. I have read and understand the above medical history questionnaire. I acknowledge that all answers have been recorded truthfully and will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form. Print Name, Parent or Legal guardian Date Signature Reviewed by/ Date 4
5 Patient Consent: Message and/or Appointment Reminders Per HIPAA Regulations Today s Date Patient Name: DOB May we leave the following types of messages at your home, work, cell, or emergency number: 1. Office appointment confirmation/changes Yes No 2. Labs and/or outpatient test results Yes No 3. Payment requirements for upcoming appointments Yes No 4. When authorization, medical records, other info needed Yes No 5. Prescription refill information Yes No Acknowledgement of Receipt of Notice As required by the privacy regulation, I hereby acknowledge that I have received a current copy of the privacy notice. I understand that is my responsibility to read through the given information, make any requests and provide documentation that may protect my confidentiality within this practice. By way of signature, I provide Inda Mowett, MD with my authorization and consent to use and disclose my healthcare information for the purposes of treatment, payment and healthcare described in the privacy policies. Signature & Date My healthcare information may be shared with the following persons: Name & relationship to patient Name & relationship to patient No, my records may not be shared 5
6 SKIN PHOTOTYPE TEST FITZPATRICK CLASSIFICATION Name: Date: Please circle the one that describes your skin type: A. Type I: Always burns, never tans. Red or blonde hair, light eyes. B. Type II: Burns easily, tans minimally. Blond hair, light eyes. C. Type III: Sometimes burns, tans gradually and uniformly. Brown hair, blue/hazel eyes. D. Type IV: Rarely burns, almost always tans well, also known as olive complexion. Brown hair, brown eyes. Most light-skinned Blacks, Latinos, and Asians. E. Type V: Rarely burns, tans profusely. Most medium-skinned Blacks, Latinos, and Asians. F. Type VI: Never burns; tans profusely, deeply. Most dark-skinned Blacks. What is your natural hair color?. Eye color?. Signature Date 6
7 Informed consent for (Photography & Media Release) I, hereby authorize Dr. Inda Mowett or any member of her staff to take before and after picture(s) of the skin treatment, procedure or weight loss program I am receiving. These photograph(s) will be used to compare the results of the treatments you have received from us. I give authorization to have only portions of my face or body to be placed in photo albums or slide presentations to show the results of my treatments. Print Name _ Sign Name Date If the above person is a minor (Under the age of 18), the signature of a parent or guardian is required below; _ Print name of Parent or Guardian Signature of Parent or Guardian Date 7
8 Check all that apply Are you interested in any of these procedures? Treatment sun damaged skin (brown spots) Face Neck Chest Hands Arms/forearms Legs Removal of fine lines and wrinkles Full face Forehead Crow s feet Lower face Neck Face and neck Facial veins & broken capillaries Full face Mid-face Nose/Cheeks Lower face Treatment of Rosacea Full face Mid-face Nose/Cheeks Lower face Botox Frown lines Crow s feet Forehead Bunny Lines Neck bands Skin Care Services Microdermabrasion Chemical Peels Skin Tightening Hand Rejuvenation Dermal Fillers Lip augmentation Smile lines Marionette s lines Smoker s lines Cheek augmentation Lower lids/sunken eyes Pulsed Light Hair Removal Beard Neck Back Chest Abdomen Underarms Forearms Upper arms Beard (male) Bikini Line Full leg Half Leg Laser acne treatment Full face Neck Upper back Complete back Chest Mesotherapy/Body Sculpting Love handles Saddle Bags Baggy eyes Inner thighs Mid/Lower abdomen Inner thighs Pre-Wedding/Special Event Package Weight Loss Programs 8
9 Facials-Dermaplaning- Peels or/ and Microdermabrasion Informed Consent I, _, have been informed by Dr. Inda Mowett, medical aesthetician or other qualified staff member of the cost of the treatment, of the treatment modalities, of secondary and unwanted side effects, of potential transient or permanent damage to my skin that may result from this procedure. The treatment has been explained to me, and I have had an opportunity to ask questions. I understand that results may not be seen in a single treatment. A series of treatments are recommended for optimal results. Possible side effects include, but are not limited to, mild redness, extreme redness, local swelling, stinging, tenderness, dry skin, flaking, pimples, bumpy appearance, cutting, scraping, and abrading the skin with a blade. There is a potential risk of exacerbation of cold sores. There is a small incidence of reactivation of cold sores (herpes infection) or bacterial infection (impetigo) in individuals with a history of these skin conditions. I understand that there is a risk of developing a temporary or permanent pigment (color) change in the skin. I have been advised to discontinue all AHA s, glycolic, Retin-A, Renova, or any exfoliating products for up to 3 days before the procedure and 3 days after the procedure. I understand there should be no sun exposure for 72 hours and that the use of an SPF 30 at all times during treatment duration is advised. I agree to have a Facial, Dermaplaning, Chemical peel, Microdermabrasion or a combination of these treatments done. I also agree to adhere to all safety precautions and the home skin care program as recommended by my practitioner. I am over 18 years of age or I have parental consent co-signed below. I will agree to inform the office of any complications or concerns I may have as soon as they occur. Client or Parent Signature Date R. 03/13 9
10 Facials-Dermaplaning- Peels or/ and Microdermabrasion After Care Instructions 1. Do not perspire for 24 hours after treatment. 2. Cleanse the face daily with a gentle cleanser. 3. Avoid direct sunlight for 72 hours after treatment. If outdoor activities are planned, wear a wide brimmed hat and SPF lotion of 30 or higher. 4. If redness or sensitivity occurs, wash your face and apply a cool compress or ice pack. If sensitivity continues for more than 24 hours, contact your physician or skin care professional. 5. Do not apply any Alpha Hydroxy acids (glycolic or lactic acid), Beta Hydroxy acids (Salicylic acid), Tretinoin such as Retin-A or Renova, or exfoliating products during your healing time as they can severely damage the skin, for up to 72 hours after procedure. 6. Do not peel, pick or scratch the skin at any time; this could cause scarring and discoloration to affected area. 7. If crusting occurs, apply petroleum jelly to affected area until healed. 8. Keep skin well-hydrated with appropriate moisturizer. Your doctor will recommend the best physician strength skin product for your skin type. 9. Call your skin care professional immediately if you experience any increased pain, redness, weeping or blistering, or have any questions about medications. Please call us at Client or Parent Signature Date R. 03/13 10
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