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Referred BY:__________________________________Patient Name:__________________________________________________________________DOB: _____________________AGE: ________Sex: ___________________Address_________________________________________________________________________________City________________________ State_____________ Zip______________Home# _____________________________ Cell #_______________________________________Email _________________________________________________Occupation _____________________________ Employer Phone# _________________________________Emergency Contact __________________________ Phone #________________________Thank you for choosing our office for all your skin care needs. If at any time you have questions regarding your treatment, please feel free to call the office 307-472-SKIN. Please note treatment fees are due at the time of service, medical insurance may not cover treatments as they are considered a cosmetic luxury. Also note that results and products are NOT guaranteed. Products, Services and Packages are non-refundable. The information above is true to best of my knowledge. I understand that I am financially responsible for my balance. Signature of Patient or Legal Guardian:_________________________ Date____________________ Please list any allergies and sensitivities: ______________________________________________________________________________________________________________________________________________________________________List any medications including supplements:____________________________________________________________________________________________________________________________________________________________________Any surgeries:_______________________________________________________________________Chronic Conditions:___________________________________________________________________*Women Only: Pregnant ___________ Breast feeding____________ Birth Control _______________Have you ever been treated for any of the following:CancerHIV/AIDSDiabetes Melanoma Dizziness/fainting Nerve Injury Skin Disease Epilepsy Mental Illness Head Injury Multiple Sclerosis Headaches/ Migraines Skin Rash Gold Therapy Have you ever used any of the following:Retin A Renova Vitamin A Accutane: Date last used:________________Steroids: Date last used: ______________Birth Control Depo ShotPrescription Acne Medication: _________ Gold Therapy Date:__________Are you currently taking any of the following:Coumadin (Warfarin)Celebrex (Celecoxib)AspirinAleve (Naproxen)Ibuprofen (Motrin, Advil)Meloxican Fish Oil Accutane (acne prescription)Do you Smoke or Vape? No____ Yes_____ Do you Tan in a Tanning Bed? No___ Yes_____ Do you get cold sores? No___ Yes___ Recent Sun Exposure? No___ Yes___Patient Self-Assessment: What is the main reason you came in for a consultation? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What aesthetic treatments have you had in the past? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you have any concerns about procedures and treatments? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you had any unpleasant treatment experiences in the past? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Products and Makeup:What skin care products are you currently using? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What brand of makeup do you use? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Massage Only Section:Circle which massage you wish to receive: Swedish, Deep Tissue, Cupping, Reflexology, RaindropWhen was your last massage?Anything you would like to change about your last massage?Have you had any alcohol in the past 24 hours? If so when and how much? On this chart indicate where you have pain: Please initial each line and sign below: _____ I understand that the information on this form is essential to determine my medical needs and provision of treatment. I will report any pertinent changes to my medical condition to the office staff as soon as possible. I have read the above questionnaire and acknowledge that all answers have been recorded truthfully and will not hold any staff member responsible for any errors or omissions I have made in completion of this form. _____ I understand that before and after photos may be taken of me and my progress. _______I authorize Stirling Skin Care Clinic to use photos of me for teaching purposes and before and after photos for publication: Yes_____ No______Patient Signature ___________________________________ Date _______________________________Witness___________________________________________ Date _______________________________Cancellation/ No Show PolicyIn our commitment to provide an outstanding experience to all of our clients and OUT OF CONSIDERATION FOR OUR CLIENT’S AND PROVIDER’S TIME, we have adopted the following policies, as of January 1st, 2020:_____ Cancellation/No Shows: At Stirling Skin Care Clinic we understand that unanticipated events occur in everyone’s life. To provide excellent services to our clients, we kindly ask if you are unable to make your appointment please give us a 24 hour notice. If you “NO SHOW” to your appointment, and fail to notify us 24 hours ahead, you will be charged a 25% fee of the scheduled appointment (due prior to rescheduling). This policy will be implemented, after your second “NO SHOW” appointment. *For Package Clients, if it is a package scheduled appointment you will forfeit 25% of the amount of the appointment, if you cancel less than 4 hours prior to your appointment. If you “NO SHOW” you will forfeit the amount of the scheduled treatment._____ Reminder Calls/Cards: Our clinic offers courtesy reminder calls and text messages the week before, two days before, and the previous business day before your scheduled appointment. If you confirm any of those reminder calls/texts you will not receive any other reminder for that one appointment. Please provide us with the best number to reach you. It is the client’s responsibility to make sure we have updated contact information. We also offer a dated card to remind you of each appointment. _____Arrival to the Clinic: Please arrive 5 minutes prior to your appointment. This allows you the time to fill out the appropriate client form, or change and prepare for the service. All services offered have a specific time scheduled and your early arrival allows for a relaxed and unhurried experience. ____Late Arrival Policy: If a client arrives late 5 minutes or more for a 15 minute appointment or 15 minutes or more for a 30 minute or longer appointment, the client will be asked to reschedule. In special cases, and if our schedule allows it, we may be able to accommodate a partial appointment. This will be at our discretion and with advanced notice of the late arrival. ................
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