www.thriveportland.com - New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.

General Patient Information
Patient Name :*

First NameMiddle NameLast Name
Date of Birth :

DayMonthYear
Age :
Occupation :
Address :*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone # :*
Work Phone # :
Cell Phone # :
Email Address :*
Emergency Contact Details
Contact Person Name :
Phone # :
Relationship of Contact :
How did you hear about us :
Patient Health History

Do any of the things listed below apply
Are you pregnant ?

YesNo
Are you nursing ?

YesNo
Trying to get pregnant ?

YesNo
HIV/AIDS ?

YesNo
History of hypertrophic/keloidal scaring

YesNo
Psoriasis

YesNo
Lupus

YesNo
Sun rash or photo allergic

YesNo
Recent exposure to sun/tanning booths

YesNo
Recent use of sunless tanning cream

YesNo
Do you freckle in the sun

YesNo
Epilepsy

YesNo
Cancer / Melanoma

YesNo
Family history of cancer/melanoma

YesNo
Diabetes

YesNo
Herpes/Cold Sore

YesNo
Folliculitis

YesNo
Pigmentation Disorder

YesNo
Heart Problems

YesNo
Pacemaker

YesNo
Date of last period

YesNo
Irregular Periods

YesNo
Menopausal Symptoms

YesNo
Total Hysterectomy

YesNo
Polycystic Ovarian Cancer

YesNo
Adrenal Hyperplasia

YesNo
Other metabolic diseases

YesNo
Recent increase in hair amount/growth

YesNo
Relatives with excessive hair

YesNo
High Stress Level

YesNo
Dental Fillings/Metal Pins

YesNo
Cosmetic Tattoos

YesNo
Taken Accutane in the past year

YesNo
Use Retin A or Alpha/Beta Hydroxy Acids

YesNo
Allergic to Lidocaine /other anesthetics

YesNo
Allergic to Vitamin B

YesNo
History of Hives

YesNo
St. John’s Wort or Vitamin E use

YesNo
Do you drink alcohol

YesNo
Do you smoke

YesNo
Are you currently under a physician’s care or have any conditions not listed above?
Please describe the nature of your visit and what you would like to accomplish with your treatment.
What medications do you take? (Please include any vitamins, herbal remedies, over the counter supplements)
Please list allergies. (Include prescription medications, over the counter medications, soy, and environmental allergies)
Have you ever undergone any cosmetic surgery, peeling procedure, dermabrasion, or any other laser treatment?

YesNo
If yes, what type and how long ago?
Check the description that would best describe you if you were exposed to strong sun with no sun block.

Always burn/Never tanAlways burn/Sometimes tanRarely burn/Always tanAmerican Indian or HispanicAfrican American
For Laser Hair Removal Patients: What is your current form of hair removal?

ShaveBleachElectrolysisPluckWaxDepilatory Creams
What skincare products are you currently using?
Cosmetic Interest Questionnaire

To help us better understand your goals please complete this questionnaire. This is optional.
What’s your actual age?
What age do you feel others perceive you as?
Check the Prefered Answer (5 – Most concerned, 1 – Less Concerned)
I feel that other people perceive me as looking angry, sad, or tired, even when I’m not.

12345
I feel that the length and thickness of my eyelashes is not what it once was.

12345
As I’ve gotten older, I’ve noticed that the color, tone, and texture of my skin has gone downhill.

12345
As I’ve aged, I’ve become more concerned with the appearance of fine lines and wrinkles around my eyes and forehead.

12345
Other than the services we are seeing you for today, what additional services Would you like to learn about? Please click all that apply.
Skin care advice/ProductsSkin care productsInjectable TreatmentsJuvederm /VolumaDermal FillerRadiesse/Belotero/RestylaneThinning lipsBotoxDysportDrooping EyelidsFacial fine lines/wrinklesFrown linesPRPNon-surgical eyelid liftUltherapyFacial veinsSpider VeinsFacial rednessBrown spots/age spots/freckleDOT / Fractional laser/FraxelScar revisionFace / neck liftAcne treatmentsMedical weight lossMenopause managementExilisCellulite TreatmentCool SculptingMicro-Needling/RejuvapenFat ReductionLaser Hair ReductionBody ContouringVanquishLaser hair removalLatisseLength / Fullness of eyelashesTattoo revisionHair regenerationTestosterone Replacement TherapyBio-identical hormonesLibido enhancement
Refund Policy

Services:
- All services need to be completed within 12 months from purchase/start date.
- Our knowledgeable Thrive staff is always available to answer any questions you may have, please make informed purchases as no refunds can be made. We will gladly issue a Thrive credit toward future services upon approval of management.
Products:
- Any unopened products returned with a receipt within 7 days may be issued a refund.
- In general, products that have been opened may not be returned. Any exceptions are up to management’s discretion.
Cancellation Policy:
- 48 Hour notice is required; otherwise a cancellation fee may be applied.
I attest that I have answered the above health questions to the best of my knowledge
Patient / Legal Guardian Name*
Date :

DayMonthYear
Should be Empty: