General New Patient Consent Form

Patient Basic Information Form:

to be filled out by the patient
Full Name

First NameMiddle InitialLast Name
Gender
Birth Date

MonthDayYear
Date
Age
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Basic Information

to be filled out by the patient
Preferred Pharmacy
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
First and Last Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?
Referral's Name (they will get $20 off their next service!)
First and Last Name
Other

Medical History
Are you currently pregnant or breastfeeding?
Are you under a doctor's care at the present time?
If yes, please explain:
Do you have allergies to any medications?
Medication
Reaction
Medication
Reaction
Medication
Reaction
Are you currently taking any medications?

Past Medical History: Have you ever had any of the following?

Rows	Yes or No	Give more detail if desired.
Gallbladder Disorder
Liver Disease
Eating Disorder
Drug or Alcohol Abuse
Psychiatric Illness
Heart Valve Disorder
Heart Disease
Cancer
Kidney Disorder
Anemia
Bleeding Disorder
Thyroid Disease
other

General Consent for Evaluation and Treatment

To the Patient:
This consent form is simply to obtain your permission to perform the evaluation necessary to identify any condition that might require an appropriate treatment, procedure, or referral as a part of your plan of care. You have the right to be informed about any condition identified and the options for recommended medical or diagnostic procedure to be used. You may then decide whether or not to undergo any suggested treatment or procedure, after being informed of the potential benefits and risks involved.

This consent provides Better Beauty and Wellness, LLC with your permission to perform reasonable and necessary medical examinations, testing, and treatment. By signing below, you are indicating that you understand that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended, along with potential risks and benefits. The consent will remain fully effective until it is revoked in writing. You have the right at any time to ask additional questions or to discontinue or decline services.

You have the right to discuss the treatment plan with your health care provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your healthcare provider, we encourage you to ask questions.

I voluntarily request a health care provider to perform reasonable and necessary medical examination, testing, treatment, and referral for the condition which has brought me to seek care at this practice.
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
Date

MonthDayYear
Date

Financial Policy

Thank you for selecting Better Beauty and Wellness, LLC for your health care. We are honored to be of service to you and your family. This is to inform you of your billing requirements and our financial policy. Please be advised that payment for all services will be due at the time services are rendered. For your convenience we accept Visa, Mastercard, Discover, American Express, Venmo, HSA/FSA cards, and CareCredit.
I have read and understand all of the above and have agreed to the financial policy:
Date

MonthDayYear
Date
HIPAA Privacy Notice

I understand that Better Beauty & Wellness, LLC follows The HIPAA Privacy Rule which requires appropriate safeguards to protect the privacy of protected health information and sets limits and conditions on the uses and disclosures that may be made of such information without your authorization. The Rule also gives you rights over your protected health information, including rights to examine and obtain a copy of your health records, request corrections, or request it be sent to another party.
I have read and understand the HIPAA Privacy Notice
Date

MonthDayYear
Date

Can't wait to see you!

If you have questions, you can contact me using the information below -- otherwise go on and hit submit!
Should be Empty:

Rows	Name of Medication	Prescription or Over-the-Counter?	Dosage	Schedule
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6

Patient Basic Information Form:

Patient Basic Information

Medical History

General Consent for Evaluation and Treatment

Can't wait to see you!