New Patient Enrollment Form

New Patient Enrollment

Juan Gonzalez MASTERS AESTHETICIAN Monica LoVerdi Nurse Practicioner
Date

Month Day Year
Date
Name

First Name Last Name
Date of Birth

Month Day Year
Sex
Contact Number:
E-mail
example@example.com
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Preferred method of communication from our office?
How did you hear about us?
Reason for consultation today
Please describe your skin and skin concerns by checking all that apply

THICK THIN SAGGY FIRM FINE LINES WRINKLED AGING DRY NORMAIL OILY COMBINATION LARGE PORES SUN FRECKLES UNEVEN/BLOTCHY ACTIVE ACNE ACNE SCARS / SCARS BLACKHEADS / WHITEHEADS CYSTS DARK SPOTS / PATCHES SCALING / FLAKING BROKEN CAPILLARIES SALLOW PUFFINESS ROSACEA DEHYDRATED ECZEMA OR PSORIASIS DARK CIRCLES / EYES Other
Are there any other treatments/conditions you are interested in hearing more about?

LONGER EYELASHES DARK SPOTS / HYPERPIGMENTATION EXCESSIVE SWEATING THINNING HAIR VAGINAL REJUVENATION SCAR TREATMENT DOUBLE CHIN FINE LINES AND WRINKLES SKIN LAXITY MEDICAL GRADE SKIN CARE ACNE Other
What is important to you when deciding on a treatment?
SKIN CARE
With what temperature water do you cleanse?

COOL WARM HOT
Do you have any special skin problems pertaining to your face and body?

YES NO
If yes, please specify
Do you experience irritation from shaving?

YES NO
Do you experience ingrown hairs?

YES NO
For unwanted hair do you

WAX TWEEZE ELECTROLYSIS
Describe your current skin care
What brand name(s) to do you use?
Do you use spf sunscreen on your face?

YES NO
Body?

YES NO
Have you had any recent sun exposure in the past 4-6 weeks, including tanning beds, bronzing creams or spray tans?If so, please specify
Are you using Retin-A, Hydroquinone (bleaching cream), glycolic acid, Accutane or any other medication that couldcause sun sensitivity?

YES NO
If yes, please explain
SOCIAL HISTORY
Do you follow a restricted diet?

YES NO
Exercise Habits/Frequency
Cigarette smoke?

YES NO
Alcohol use?

YES NO
Drug use?

YES NO
If yes, please explain
Do you have regular sleep patterns?

YES NO
Do you consume caffeinated products?

YES NO
If yes, please explain
MEDICAL HISTORY
Name of Primary Care Provider
Office Phone
Illnesses (past five years):Type a question
Chronic or Current Conditions

Neurologic conditions Cardiovascular conditions Respiratory conditions Endocrine disorders Liver conditions Kidney conditions Autoimmune conditions Infectious diseases Coagulation disorders Hereditary conditions Connective tissue disorders Cancers Eye conditions Skin conditions Psychological conditions Surgery, (incl. cosmetic)
EXPLAIN
Do you faint easily?

YES NO
Do you scar easily?

YES NO
Do you have any allergies?

YES NO
EXPLAIN
Drug Therapy
Please list any prescribed or over the counter oral or topical medications you are currently using, including: allergymedications, acne treatments, Aspirin, Ibuprofen, herbs & vitamins
SKIN CARE
Have you ever had a chemical peel?
Last treatment date
Have you recently had microdermabrasion?
Last treatment date
Have you ever had any laser or photofacial treatments in the past?
Last treatment date
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin), keloid scars ormarks/scars from physical trauma, chicken pox or acne?

YES NO
If so, please describe
Do you have any permanent cosmetic tattoos?
Have you ever had Botox® or Dysport® injections?
Last treatment date
Area treated
Have you had previous dermal filler, Kybella™or Sculptra® injections?
Last treatment date
Area treated
Frequent or occasional cold sores to mouth or genitalia?

YES NO
Do you wear contact lenses?

YES NO
For women only
Could you be pregnant?

YES NO
Are you breastfeeding?

YES NO
Are your menstrual cycles normal?

YES NO
Birth Control Pills?

YES NO
Menopausal/peri menopausal hormone replacement therapy?

YES NO
Periodic acne flare-ups related to cycle?

YES NO
In case of emergency
Emergency Contact:

First Name Last Name
Relationship
Contact Number
Photo authorization release
In order to track our progress, we at PellRadiant like to incorporate the use of photos. It helps us to thoroughly see the changes in your body from beginning to end.Photos are to be used for documentation purpose, & if consented as advertisement for theproduct, and/or service etc.

I consent to having "Before" and "After" photographs of my service/procedure Photographs will be used for the purpose of documentation.These photographs MAY be used for advertising purposes I understand, by signing this form, I am allowing PellRadiant & Staff to disclosephotographs taken of me before, during, and after treatment. I understand that once my photographs have been disclosed to PellRadiant Skin Health, affiliates, successors and assignees the photographs will no longer be protected by federal privacy laws. However, PellRadiant Skin Health's affiliates, successors, and assignees will not use the photographs except as permitted on this authorization form.I hereby release PellRadiant Skin Health, its affiliates, successors, and assignees from any claim demand, cause, action, or proceeding of whatever nature arising out of publication and distribution of the said photographs in accordance with the terms of this authorization.By signing this form, I am allowing PellRadiant Skin Health, affiliates, successors and assignee to disclose photographs taken of me before, during, and after treatment.
Spa Policy’s
Check-In Processes:

Please make sure to arrive at least 15 minutes or earlier prior to your appointment to ensure
full service. Upon your arrival, you will be greeted by the PellRadiant Skin Health Staff.

Late Arrivals:
In the event of a late arrival, if possible, we will attempt to accommodate all your
needs. However, in consideration of other guests’ time and schedule, PellRadiant Skin Health may
not be able to extend your appointment. Late arrivals may very well limit the time of your
treatment. Treatments are to begin, and end as scheduled and full value of the service will be
charged regardless of arrival time. In these situations, we would be more than happy to service
you for the remainder of your scheduled appointment.

Cancellation/ No Show Policy:
We understand that there are times when you must miss an appointment due to emergencies
or obligations for work or family. However, when you do not call to cancel an appointment, you
may be preventing another patient form getting a much-needed service. Conversely, the
situation may arise where another patient fails to cancel, and we are unable to schedule you for
an appointment. If an appointment is not canceled at least 24 hours in advance you will be
charged a twenty-five ($25) fee.
Patient Signature

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New Patient Enrollment

SKIN CARE

SOCIAL HISTORY

MEDICAL HISTORY

Drug Therapy

SKIN CARE

For women only

Photo authorization release

Spa Policy’s