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 Contact Phone Primary Care Physician Preferred Pharmacy Occupation Whom should we thank for referring you? 1
Fitzpatrick Skin Classification (Please Circle Appropriate Response) Type I: Always burns easily, never tans; extremely sun sensitive; red hair; freckles, Celtic, Irish or Scottish descent. Type II: Always burns easily, tans minimally; very sensitive skin; fair hair, blue eyes; Caucasian descent. Type III: Sometimes burns, tans gradually; average skin Type IV: Burns minimally, always tans to moderate brown, minimally sun sensitive; Mediterranean, Caucasian, Asian descent. Type V: Rarely burns, tans well; sun insensitive skin; Middle Eastern, some Hispanic, and some African American descent. Type VI: Never burns, deeply pigmented; sun insensitive; African American descent. AESTHETIC HISTORY What hair removal methods have you used in the past six weeks? Shaving Waxing Electrolysis Tweezing Chemical Depilatories Have you had previous laser skin therapy? (IPL- intense pulse light or Photofacial, radio frequency, infrared, Thermage, or other modalities) YES NO Have you used Accutane? YES NO Are you currently using any topical medications? (Retin-A or Tazorac) YES NO What skin products are you currently using? Do you use sun protection (SPF, hat, etc.) on a daily basis? Are you satisfied with your skin care regimen? INJECTABLES Have you had previous Botox or Dysport injections? YES NO Have you had previous collagen or dermal filler injections? YES NO 2
Please complete the following medical questionnaire. The answers you provide will better enable us to care for you and your aesthetic or medical needs. Please circle the appropriate response. YES NO Heart Disease: Angina, High Blood Pressure, Murmur, Pacemaker, Poor Circulation YES NO Lung Disease: Asthma, COPD, Sleep Apnea YES NO Neuromuscular Disease: Multiple Sclerosis, Myasthenia Gravis YES NO Liver Disease YES NO Kidney Disease YES NO Diabetes, Hypoglycemia, Thyroid Disease YES NO Gastrointestinal Disease YES NO Cancer YES NO Autoimmune Disease, Lupus, Rheumatoid Arthritis YES NO Bleeding Disorder or Blood Clots YES NO GYN Issues: Polycystic Ovarian Syndrome YES NO Pregnant or Breast Feeding YES NO Skin Disease: Psoriasis, Eczema, Rosacea, Acne YES NO Infectious Disease: Herpes, Cold Sores, HIV/AIDS YES NO Tobacco, Alcohol or Recreational Drug Use CURRENT MEDICATIONS (Including herbs, vitamins, supplements, minerals and homeopathic remedies) Include Name and Dosage: ALLERGIES (Please list all allergies including topical and oral medications, preparations and foods): SURGERIES 3
Please circle all services you are Interested in: Dermal Fillers Chemical Peels Skin Rejuvenation Microdermabrasion Hair Removal Facials Fractional Laser Treatment Sun damage/age spot correction Neuro Toxin Cosmetic (BOTOX or DYSPORT) Thank you for your time! Patient Signature Date Physician/APRN/LMET Review 4
Patient Communication Policy Please read this new policy, which pertains to all patient inquiries and requests sent through Patient Fusion. Due to the increasing number of electronic communications, and in order for you to receive a response in a timely manner, please enroll in our Patient Fusion Portal. Once you enroll you will be able to access lab results, request appointments, message providers, ask questions/make requests. Please make questions and requests brief and concise. If your questions or concerns are beyond the scope described above, and/or require more time and attention, you will be asked to schedule an appointment. **NOTE** Due to HIPPA regulations and the unsecure nature of text message, Imbue Aesthetics & Wellness does not disclose any medical information via text message and discourages all patients from using text message for medical information. Thank you for your understanding and cooperation. Name (Print) Name (Sign) Date Cancellation Policy would like their patients to be aware of the cancellation policy regarding appointments made by and between the company and patient who has scheduled an appointment and failed to arrive for scheduled appointment, failed to call, or failed to reschedule. After 2 missed appointments or failing to give 24 hour courtesy notice to reschedule or cancel an appointment we will require a 50% deposit prior to scheduling your next appointment. If the appointment you miss or fail to reschedule within the 24 hour courtesy period is part of a package you have purchased, we will deduct a treatment from that package after 2 missed appointments or failure to reschedule within 24 hours of your appointment. Your punctuality is greatly appreciated, so that we are able to dedicate the appropriate amount of time to your scheduled treatment/service. Lateness of more than 10 minutes will result in rescheduling your appointment. Thank you for your understanding and cooperation. Name (Print) Name (Sign) Date 5