Coolspa (UES) Patient Intake
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  • SPOUSE OR PARTNER CONTACT INFORMATION [If applicable]

  • EMPLOYMENT INFORMATION

  • EMERGENCY CONTACT INFORMATION:

  • Height: * feet * inches

  • Weight: * lbs

  • PHARMACY INFORMATION:

  • PERSONAL MEDICAL HISTORY:

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  • Assignment & Release

  • I   *   *  assign directly to Dr. David P. Rapaport and associates all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges incurred. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.

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  • David P. Rapaport, M.D., & associates feels strongly about his patients' privacy as well as his practices' right to control its public image and privacy. David Rapaport, M.D., and associates agrees not to be paid for selling patients lists or protected health information to any third party for the purpose of marketing directly to his patients. In consideration for treatment and the above noted Patient protection, Patient agrees to refrain from directly or indirectly publishing or airing commentary upon the Physician; and they will use all reasonable efforts to prevent any member of their family from engaging in such activity. David Rapaport, M.D., and associates has the right to equitable relief to prevent the initiation or continuation of publishing or airing of commentary upon his practice, expertise and/or treatment. Both Physician and Patient will work to prevent the publishing or airing of commentary about the other party from being accessed via internet, blogs or other electronic, print or broadcast media without prior written consent. Finally, this Agreement shall be in force and enforceable for a period of five years from Physician's last date of service to Patient. Patient has been given the opportunity to ask questions and receive adequate answers to his/her satisfaction. Refund policy: Please note that our office does not provide refunds on any services rendered. All sales, including deposits for treatments, are final. Skincare products may be exchanged if damaged or unused within 14 days of purchase.

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  • Cosmetic Questionnaire

    Our practice strives to offer patients the most-advanced, personalized procedures for facial rejuvenation and overall appearance 
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