PATIENT INFORMATION Date MM slash DD slash YYYY NAME AGE BIRTH DATE MM slash DD slash YYYY ADDRESS STREET ADDRESS CITY STATE ZIP CODE HOME PHONEBUSINESS PHONEMOBILE PHONEEMAIL PHARMACY PHARMACY # EMERGENCY CONTACT EMERGENCY # Is there a number a message can be left regarding treatment? Would you like to receive emails regarding discounts/specials? Yes No How did you hear about us? Referral from a friend Referral from a Doctor/employee Internet/Website/Social Media Other Have you ever seen one of our Plastic Surgeons at DPSI? Yes No Which Dallas Plastic Surgery Physician have you seen? RESPONSIBLE PARTY: (IF A MINOR)Name Relationship to Patient Address Street Address City State / Province / Region ZIP / Postal Code PhonePATIENT MEDICAL HISTORYPatient Name Date MM slash DD slash YYYY DOB MM slash DD slash YYYY Gender Check all nationalities associated with your genetic makeup: Caucasian Hispanic Middle Eastern Native American German Italian Asian Mediterranean African American Irish Greek Spanish AllergiesMedication Type of of Reaction Food Lidocaine Seasonal What brings you in today? Fine lines/wrinkles, wrinkles with movement Deep folds around nose/mouth Thinning lips Sagging skin/tissue (face/body) Acne/Rosacea Skin dullness Volume loss Enlarged pores/acne scars/scars Skin discolorations (Hypo/hyperpigment, redness) Rough skin texture/dryness Unwanted body fat Excessive/unwanted perspiration Cellulite/dimpling Other Are there any other areas of concern?Any history of adverse reaction to treatments? Excessive swelling/Angioedema post tx Headache post Botox Loss of pigment Lidocaine sensitivity Fat growth after CoolSculpting Post inflammatory hyperpigmentation Prolonged bruising/bleeding Prolonged healing/recovery Prolonged pain Stress Incontinence Vaginal dryness Vascular occlusions Cold sore eruption Other Medical History Cold sores/HSV Acne/rosacea Alopecia/hair loss Atopic dermatitis Autoimmune disorder Bleeding disorders Cancer Depression/Anxiety Diabetes Eczema/psoriasis GI disorders H/O chicken pox/shingles Heart disease Hernias Hepatitis C HIV/MRSA/Tb//G+ High blood pressure Hypo/hyperthyroidism Liver/kidney disease Lung disease (COPD/Asthma) Melasma/Pregnancy mask Metal implants/Stent/Pacemaker/Defibulator Migraines NM/motor neuron disorders/stroke Bells Palsey/Guillain Barre Scars (keloid/surgical/traumatic) Seizure/Vertigo Skin cancer Skin moles/lesions Sleep apnea/CPAP Menses Pregnant or trying Lactating Other Surgical History Tummy Tuck Eyelid surgery Breast aug/reduction/lift Deep laser resurfacing Dental implants Face lift (upper/lower/nec) Facial implants: Location Hernia repair Joint replacement Liposuction Rhinoplasty Other Past Aesthetic Procedures Chemical Peels Skin tightening Microblading/Perm Makeup Fat reduction Dermal filler Botox Kybella Laser Treatments PDO threads Sculptra Other Social HistoryMarital Status Skincare/SPF Occupation Use of Retin A/Retinol Sun exposure _____ hours per day/wk/mo Skincare/SPF Tobacco: Cigs/day __ years__ Quit Date _____ Alcohol Intake ______drinks per day/wk/mo Occupation Illicit Drug Exercise type __________hrs/week____ Medications/Supplements/Vitamins - Please List AllName | Reason for Taking | Frequency/DosePatient Signature: By typing your name below, you are providing your electronic signature, acknowledging that you understand and agree to the terms of this consent. Date MM slash DD slash YYYY PHOTO CONSENT & NOTICE OF PRIVACY PRACTICES PHOTO CONSENT I consent for medical photographs to be taken of me by staff at EpiCentre Skin Care & Laser Center/EpiCentre Park, PLLC/Dallas Plastic Surgery Institute. I understand that the information may be used in my medical record, for purposes of medical teaching, or for publication in medical textbooks or journals. By consenting to these medical photographs I understand that I will not receive payment from any party. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone may recognize me. Refusal to consent to photographs will in no way affect the medical care I will receive. If I wish to withdraw my consent in the future, I may do so with a written request.I authorize the use of these images:For demonstration purpose including an office photo album YES NO On our website and social media for prospective patients YES NO In print advertisements and/or professional journals YES NO Consent By signing this form, I confirm that this consent form has been explained to me in terms which I understand.NOTICE OF PRIVACY PRACTICES I acknowledge and agree that my protected health information must be protected according to EpiCentre Park, PLLC’s Notice of Privacy Practices and that I have the rights to access and control such information. I acknowledge and agree that I have had all my questions regarding the use or disclosure of my protected health information and my associated rights answered to my satisfaction. While patient anonymity is preserved, there may be incidental identification through the imagery, which I accept. This consent is granted for medical education, research, or public welfare purposes, and I/we waive any rights to the imagery, releasing EpiCentre Park, PLLC/The Dallas Plastic Surgery Institute and its personnel from any related claims or liabilities.SIGNATUREPatient or Patient/Guardian Name Patient or Patient/Guardian Sign: By typing your name below, you are providing your electronic signature, acknowledging that you understand and agree to the terms of this consent. Relationship to patient Witness Date MM slash DD slash YYYY CANCELLATION & RETURN POLICY CANCELLATION POLICY Your appointments are very important to the team members of EpiCentre and these times are reserved especially for you. We understand that sometimes schedule adjustments are necessary; therefore, we respectfully request at least 24 hour notice for cancellations. STRICT AND ENFORCED 24 HOUR CANCELLATION POLICY! Please understand that when you forget or cancel your appointment without giving enough notice, we miss the opportunity to fill that appointment time and patients on our waiting list miss the opportunity to receive services. Our appointments are confirmed 48 hours in advance because we know how easy it is to forget an appointment you booked months ago. Since the services are reserved for you personally, a Cancellation Fee will apply. 1. Less than 24 hour notice will result in a charge equal to 50% of the reserved service amount. 2. “NO SHOWS” will be charged 100% of the reserved service amount. If you prepaid for a service or package, that service will be taken out of your package as if it were used at that particular time. 3. Appointments made within the 24 hour period and need to cancel, the patient must cancel within 4 hours of appointment time or will result in a charge equal to 50% of the reserved service amount. 4. Please understand late arrivals will not receive an extension of scheduled services in order to prevent inconvenience to the next patient scheduled and the same treatment price will apply. 5. Any service requiring a 2 hour or more appointment time, will require a 50% deposit to hold that particular appointment. Our Cancellation Policy allows us the time to inform our standby patients of any availability, as well as keeping our EpiCentre team member’s schedules full, thus better serving everyone. EpiCentre policies are presented and provided in the best quality and tradition of excellent service for our established and future patients. Thank you for viewing and supporting our policies criteria. RETURN POLICY * Absolutely NO refunds on services, packages or products. * All pre-paid services and packages must be used within one year from the date of purchase. * Product returns or exchanges must be within 30 days from date of purchase and must be unopened with your receipt. A credit will be issued to be used within EpiCentre Print Name Signature: By typing your name below, you are providing your electronic signature, acknowledging that you understand and agree to the terms of this consent. Date MM slash DD slash YYYY
