Www.scgskin.com
Date:______________Patient InformationLast Name____________________________ First Name_________________________ Middle Name________________Address____________________________________________________________________________________________City_____________________________________________________________ State___________ Zip_______________Home Phone_______________________________________ Cell Phone_______________________________________Email______________________________________________DOB_______________How do you prefer we contact you? (circle)Home-call Cell-call Text EmailOkay to leave a voicemail? _____________How did you hear about us?___________________________________________________________________________Reason for consultation/appointment_____________________________________________________________________________________________________________________________________________________________________Emergency contact name_____________________________________________ Number_________________________ Relationship to patient_______________________Medical InformationMedication Allergies and type of reaction __________________________________________________________________________________________________________________________________________________________________All other allergies or sensitivities (including cosmetics, ingredients & aromas)_____________________________________________________________________________________________________________________________________Are you sensitive or allergic to Latex? ___________________________________________________________________Have you had any difficulties with general or local anesthesia, including numbing medicine or anesthetics, either topical or injected? ________________________________________________________________________________________Have you ever had any excessive bleeding with tooth extractions, cuts or surgery? _________________________________________________________________________________________________________________________________Have you ever been told that you have skin cancer or pre-cancerous lesions?_____________________________________________________________________________________________________________________________________Do you have any active skin diseases or infections, including herpetic lesions or cold sores?__________________________________________________________________________________________________________________________Medical Information Cont’dHave you taken Accutane, Retin-A, Renova, Differen, Tazarac or Gycolic in the past 30 days? ______________________Name, dosage and last date of use______________________________________________________________________Have you undergone a peel in the last 3 months?____________ If yes, when?___________________________________Have you ever been told that you have any neuro-muscular disease? (ALS/Lou Gehrig’s, Myasthenias Gravis, Muscular Dystrophy, stroke or TIA). Explain ________________________________________________________________________________________________________________________________________________________________________Have you ever been told that you have a true cow’s milk or egg protein allergy? (NOT lactose intolerant)_____________Have you ever been told that you have keloids or problems with scarring?_____________________________________Do you have/have you had any tumors or growths? If yes, please explain_________________________________________________________________________________________________________________________________________Have you had Radiation and/or Chemotherapy?_________ If yes, when?______________________________________Are you currently being treated for any medical/surgical condition?___________________________________________Have you ever experienced hyperpigmentation from an injury?_______________________________________________Have you ever seen a physician for your skin? ________ Doctor________________________ Date last seen___________What products do you use for skin care?___________________________________________________________________________________________________________________________________________________________________For womenDate of your last menstrual cycle________________ Do you have regular periods?__________ Could you possibly be pregnant?__________________ Are you breast feeding?____________Are you planning pregnancy during the course of your treatment?____________________________________________MedicationsPlease list all medications, including prescribed, over the counter, occasional, vitamins, herbs, supplements, and those purchased inside or outside of the US. Please include name, dose and frequency.____________________________________________________________________________________________________________________________________________________________________________________________________Have you taken any blood thinning medication or substance within the past 30 days? (Examples include Coumadin, Aspirin, Ibuprofen, Vitamin-E, fish oils, omega 3, flaxseed and herbal anti-inflammatories)._________________________Please include name, dose and frequency.__________________________________________________________________________________________________________________________________________________________________Surgical HistoryPlease list all surgeries and/or serious injuries and dates________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please check all that apply SELF PARENT OTHER SELF PARENT OTHERBlood Pressure ProblemsHepatitisKidney Disease DiabetesAnemiaArthritisBleeding DisorderLupusStrokeAutoimmune DiseaseLung DiseaseHIVEpilepsyCold SoresFainting/DizzinessCirculatory ProblemsCataractsDry EyeGlaucomaCorneal AbrasionEyesAre you using any eye drops or other ocular medications? _______ If yes, please explain.___________________________________________________________________________________________________________________________When was your last eye exam? ___________________ Do you wear contacts?___________________Have you had any eye/eyelid surgery or injury? _______ If yes, please explain._____________________________________________________________________________________________________________________________________Have you ever received injections of Botox/Dysport? __________ Type________________________________________Date______________ Results__________________________________________________________________________Have you ever received injections of Dermal Fillers? __________ Type_________________________________________Date______________ Results__________________________________________________________________________Social HistoryDo you smoke?_________ Packs per day_____________________________ For how many years?__________________Do you consume alcohol?_________ Amount per week_________________________ Date of last drink_____________Do you use any other substances?_________ List__________________________________________________________Do you exercise?__________ Type and frequency__________________________________________________________Do you sunbathe?_________ Date of last sun/tanning bed exposure__________________________________________Do you use sunscreen?________ Type________________________________________________ SPF_______________Payment Agreement: I understand that payment is due when services are rendered. I understand that I am financially responsible for all charges. I agree that all unpaid balances are subject to a collection fee, which is also my responsibility. I authorize release of any information necessary to secure my payment. I agree to contact SCG Skin Rejuvenation at least 24 hours prior to my appointment if I need to cancel or reschedule. I understand that I may be required to pay a 50% fee for a missed service (up to a $50 fee) if proper notice is not given. I understand if I arrive late for my appointment, I may be required to reschedule my appointment to avoid delaying the appointment of another scheduled patient. If I am asked to reschedule my appointment, I understand I may be required to pay a cancellation fee.Patient Signature________________________________________________________________ Date________________Reviewed by___________________________________________________________________ Date________________Medical Director________________________________________________________________ Date________________Annual SignaturesSignature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________Signature______________________________________________________________________ Date________________ ................
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