• Medical Spa Intake

  • Patient

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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • Marital Status:

  • Responsible Party

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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Marital Status:
  • Race:
  • Ethnicity:
  • How did you hear about us?

  • Protected Health Information/PHI:

    Arctic Medical Center takes pride in protecting your information. If you would like our office to discuss your health information with anyone, please indicate this below.

  • NOTICE OF PRIVACY PRACTICE

  • This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition, we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances.

    1. Treatment purposes - discussion with other health care providers involved in your care.
    2. Inadvertent disclosures - open treating area mean open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room.
    3. For payment purposes - to obtain payment from your insurance company or any other collateral source.
    4. For workers compensation purposes - to process a claim or aid in investigation.
    5. Emergency - in the event of a medical emergency we may notify a family member.
    6. For Public Health and Safety - to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.
    7. To Government Agencies or Law Enforcement - to identify or locate a suspect, fugitive, material witness or missing person.
    8. For military, national security, prisoner, and government benefits purposes.
    9. Deceased persons - discussion with coroners and medical examiners in the event of a patient’s death.
    10. Telephone calls or emails and appointment reminders - we may call your home and leave messages regarding a missed appointment or appraise you of changes in practice hours or upcoming events.
    11. Change of ownership- in the event this practice is sold, the new owners would have access to your PHI.

     

    YOUR RIGHTS:

    1. To receive an accounting of disclosures.
    2. To receive a paper copy of the comprehensive “Detail” Privacy Notice.
    3. To request mailings to an address different than residence.
    4. To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.
    5. To inspect your records and receive one copy of your records at no charge, with notice in advance.
    6. To request amendments to information. However, like restrictions, we are not required to agree to them.
    7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours). X-rays are original records, and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost.

    I have received a copy of the Patient Privacy Notice. I understand my rights as well as the practice’s duty to protect my health information and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this “Notice of Privacy Practice” at a time in the future and will make the new provisions effective for all information that it maintains past and present.

    I am aware that a more comprehensive version of this “Notice” is available to me. At this time, I do not have any questions regarding my rights or any of the information I have received.

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  • FEMALE SEXUAL DISTRESS SCALE

    Revised
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  • Below is a list of feelings and problems that women sometimes have concerning their sexuality. Please read each item carefully and check the box that best describes how often that problem has bothered you or caused distress over the last 4 weeks including today.

    Please check only one box for each item and take care not to skip ANY items. If you change your mind, change your markings carefully.

    Please Check One Box Per Question

  • 1. How often did you feel distressed about your sex life?
  • 2. How often did you feel unhappy about your sexual relationship?
  • 3. How often did you feel guilty about your sexual difficulties?
  • 4. How often did you feel frustrated by your sexual problems?
  • 5. How often did you feel stressed about sex?
  • 6. How often did you feel inferior because of sexual problems?
  • 7. How often did you feel worried about sex?
  • 8. How often did you feel sexually inadequate?
  • 9. How often did you feel regrets about your sexuality?
  • 10. How often did you feel embarrassed about sexual problems?
  • 11. How often did you feel dissatisfied with your sex life?
  • 12. How often did you feel angry about your sex life?
  • 13. How often did you feel bothered by low desire?

  • Consent for O-Shot® and Administration of Local Anesthesia

  • A. CONSENT FOR PROCEDURE [O-Shot(R)]
    The O-shot procedure consists of taking PRP and injecting between the urethra and the vagina, parallel to the internal location of the Skene’s glands. The optimal outcome would be to increase sexual arousal, help control urinary incontinence, and help dryness. 

    1. I authorize Erika Dominick, CRNP to treat my condition(s), including performing further diagnosis and the procedure(s) described below.
    2. I understand the proposed procedure(s) to be: vaginal submucosal/sub urethral, clitoral, and labial, PRP (platelet rich plasma) injection [The Orgasm Shot(R)/The O-Shot(R)].
    3. I understand the risk(s) associated with the proposed procedure(s) to be: Bleeding, infection, urinary retention, allergic reaction, abnormal sexual sensation continuing without stimulation, vaginal discharge, sexual function alternation, hematoma, urethral injury, urinary retention, hematuria (blood in urine), urinary tract infection (UTI), urinary urgency/frequency, increased/worsened nocturia, change in urinary stream, urethral/vaginal fistula, painful intercourse, need for subsequent procedures, alternation of vaginal sensation, scar formation, urethral stricture, local tissue infarction/necrosis, yeast infection, spotting between menses, bladder pain, overactive bladder, bladder fullness, pelvic pain/heaviness, erosions, fatigue, post-procedural pain, failed procedure, varied results, decreased sexual function, possible hospitalization d/t complications, lidocaine toxicity, anesthesia reaction, embolism, depression, anaphylactic reaction to lidocaine or calcium chloride, nerve damage, slow healing, swelling.
    4. I also understand that there may be other risk(s) and or complication(s), and or serious injuries from both known and unknown cause(s). I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantee(s) have been made to me concerning the risk(s) of the procedure. 
    5. I understand that the use of PRP in this procedure is an ‘off label’ use, no promise(s) and or representation(s), guarantee(s) and or warranty regarding its use, benefit(s), and or other qualities were made. I have been informed by the provider of other alternative(s) and I understand the alternatives as they were explained to me  
    6. No representation(s) that the use of the product(s) and the procedure(s) are approved by the FDA and or any other agencies of the federal and or state government were made.  
    7. No video(s), picture(s), and or recording(s) in the office and or during the procedure(s)   


  • B. CONSENT FOR ANESTHESIA:
    When local anesthesia and or sedation is used by the provider: I consent to the administration of such local anesthetics as may be considered necessary by the provider in charge of my care. I understand the risk(s) of local anesthesia include but are not limited to: local discomfort, swelling, bruising, allergic reactions to medications, and seizures from lidocaine.

    C. PATIENT CERTIFICATION:
    I have received information about my condition, the proposed treatment, alternative(s), and related risk(s). This form contains a summary of this information. I have received an explanation of any unfamiliar terms and have been offered the opportunity to ask questions. I understand I may refuse consent at any time. I have read and understand this form, and I give my informed and voluntary consent to the proposed procedure(s). I also consent to the performance of any additional procedure(s) determined by my provider during the procedure(s). By signing below, I state that I am 18 years of age or older, or otherwise authorized to consent.

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  • E. INTERPRETER ATTESTATION (when applicable)
    I have provided translation to the person(s) whose signature(s) is affixed above.

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  • Should be Empty: