About Face

About Face

Registration Form
Client Name*

First NameLast Name
Preferred Name

First NameLast Name
Date*

MonthDayYear
Date
Birth Date*

MonthDayYear
Date
Are you under the age of 18?*

YesNo
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
May we contact you at work?*

YesNo
Email*
Confirmation emails are sent one day before appointments. We will not share your contact information with anyone unless given explicit permission.
How did you find us? Were you referred to us?*
May we email you with an appointment confirmation message and with information about our open house events and seasonal specials?*

YesNo
Emergency Contact Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Authorization for use or disclosure of health information (HIPAA)
This HIPAA form requests you to advise: (a) to whom we may disclose information, (b) the reason for disclosure, and the information to be disclosed. However, to further protect your right to privacy, About Face Cosmetic Therapy Center, Inc. will not use or disclose health information to family members, doctors, insurance companies, health insurance companies or to any other entitles without a current written authorization at the time the information is to be released.
Signature

Clear
Date*

MonthDayYear
Date
Please fill in below only if/when releasing information
About Face may discuss your health and/or treatment with/will provide your information to:

I. I,   First Name   Last Name   hereby authorize the disclosure of my health/treatment
information from my records to:
Name:   Name
Address:   Street Address   Address Line 2   City   State   Zip

II. The purpose/ reason for this disclosure is:


III. The information I authorize to be disclosed from my health/treatment
Records. Please initial the appropriate box(es)
Entire record   Visit notes   Billing   History and Physical   Medications   List

Other information related to (specify):
Appointment confirmation will be by email or text.
Should be Empty:

Emergency Contact Information

Authorization for use or disclosure of health information (HIPAA)

Please fill in below only if/when releasing information