New Patient Visit Form

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Dates at the seasonal address

Area CodePhone Number

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

**Please provide even if retired**

Area CodePhone Number

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

SelfPCPOther Physician's Name

Area CodePhone Number

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

SelfSpouseParentLegal Guardian

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Area CodePhone Number

These questions are included to comply with new Federal Health guidelines - we are required to ask for this information:

Hispanic or LatinoNot Hispanic or LatinoDeclined

Please check how you would like to be notified: I permit Ohio Skin Care Institute to disclose my protected Health Information: for the purpose of appointments/test results/ procedure reminders and follow-up; by leaving such information in the form of a message on the following:

Home TelephoneCell PhoneEmail

You may discuss any of my medical information with the following individuals: If you would like to permit someone to discuss your medical condition, confirm appointments or obtain results for you, please indicate their names below. Only these individuals will be provided with the information. Should you wish to update the names provided below, Please ask the receptionist.

Area CodePhone Number

Living WillPower of AttorneyDNRN/A


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Current smokerFormer SmokerNever Smoker

Consume less than one alcoholic beverage a dayConsume 1-2 alcoholic beverages a dayConsume 3 or more alcoholic beverages a day

	YES	NO
Rash
Bleeding Problems
Difficulty Healing
Problems with scarring hypertrophic or keloid)
Hay Fever
Wheezing
Fever or Chills
Chest Pain
Shortness of Breath
Cough
Joint Aches
Muscle
Weakness
Thyroid Problems
Depression
Anxiety
Headaches
Neck Stiffness
Sore Throat
Blurry Vision
Night Sweats
Unintentional Weight Loss
Abdominal Pain
Bloody Urine
Bloody Stool
Open sores or draining wounds
Other

Fillers: Voluma/Juvederm®/Restylane®/Radiesse®/Sculptra®/OtherOther

New Patient Visit Form

New Patient Information

Pharmacy

Person Responsible for Payment

INSURANCE

Emergency Contact

Appointment Reminders, Laboratory Results and Billing

Current Medical Condition

Medications

Medication Allergies/Reactions

Past Medical History

Past Surgical History

Skin Disease History

Alerts

Social History

Are you currently experiencing any of the following?

Aesthetic Questionnaire