Patient Medical History Form

General Patient Information
General Patient Information

Please Complete
Patient Gender *
Patient Name *

First Name Last Name
Patient Birth Date *

Month Day Year
Cell Phone Number

Area Code Phone Number
Patient Height (inches) *
Patient Weight (Ibs) *
Patient E-Mail *
Reason for seeing the Medical Provider: *
Patient Medical History
History of any Allergies to Medications *

No Known Drug Allergies Yes, proceed to fill in box names of each medication and allergic response
Please list any drug allergies *
History of any Medical Illnesses/Conditions/Diseases *

No Yes, proceed to complete below list of all medical illnesses/conditions/diseases
Have you ever had (Please check all that apply) *

Anemia Asthma Arthritis Blindness Cancer Gout Diabetes Emotional Disorder Epilepsy Seizures Fainting Spells Gallstones Heart Disease Heart Attack Rheumatic Fever High Blood Pressure Digestive Problems Ulcerative Colitis Ulcer Disease Hepatitis Kidney Disease Liver Disease Sleep Apnea Use a C-PAP machine Thyroid Problems Tuberculosis Venereal Disease Neurological Disorders Bleeding Disorders Lung Disease Emphysema Insomnia Shortness of Breath Vertigo Other, list below
Other illnesses:
History of any Surgical Procedure including Cosmetic Surgical *

No Yes, proceed to complete below in box list of all and year
Please list any Surgery and Year of Each
Healthy & Unhealthy Habits
Exercise *

Never 1-2 days 3-4 days 5+ days
Eating following a diet *

I have a loose diet I have a strict diet I don't have a diet plan
Alcohol Consumption *

I don't drink 1-2 glasses/day 3-4 glasses/day 5+ glasses/day Only Special Occasions Only Holidays Every Weekend 1-2times a week 3-4times a week 5-6times a week
Caffeine Consumption *

I don't use caffeine 1-2 cups/day 3-4 cups/day 5+ cups/day
Do you smoke? *

No 0-1 pack/day 1-2 packs/day 2+ packs/day
Include other comments regarding your Medical History
FINANCIAL RESPONSIBILITY POLICY *

Payment for services is expected at time of service. Insurance is NOT applicable to cosmetic/aesthetic dermatological procedures, I authorize benefits to be paid directly to Concierge Health & Rejuvenation Solutions, LLC I am responsible for the balance on my account, regardless of insurance coverage. My failure to pay off outstanding balances on my account may result in collection procedures being taken. I authorize the Medical Provider to release any information requested with regard to the processing of my claims. Failure to give 24 hour notice prior to canceling appointments may result in a cancellation fee charge to my account not payable by health insurance.
MISSED / LATE APPOINTMENT POLICY *

I must provide at least 24-48 hours notice if I need to reschedule or am unable to make my appointment. I understand that if I frequently miss appointments or I am frequently late for appointments I give authorization for my credit card to be billed $100 for late or missed or cancelled booked appointments for cosmetic services. I understand that if I frequently miss/cancel appointments less than 48hrs prior to appointments or I am frequently late for appointments then a credit card may be required to book future appointments. I also understand that a deposit of $200.00 or more will be required to book appointments for cosmetic services.
A Notice of Privacy Practices (NPP) is provided to all patients. This Notice of Privacy Practices identifies:

How medical information about you may be used or disclosed;
Your rights to access your medical information, amend your medical information, request an accounting of disclosures of your medical information, and request additional restrictions on our uses and disclosures of that information;
Your rights to complain if you believe your privacy rights have been violated; and
Our responsibilities for maintaining the privacy of your medical information.
Per federal law, Concierge Health & Rejuvenation Solutions, LLC is committed to protecting the privacy of your medical information, neither this company nor its employees or owners or assignees will release any medical or financial information to any person or agency without the expressed written or witnessed consent of the Responsible party designated above.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that governs the use and disclosure of a person’s health information. Our “Notice of Private Practice” provides information about how we may we disclose protected health information about you. The Notice contains a “Patient Rights “describing your rights under the law. The following statements cover the basics of your rights as a patient under HIPPA.

Protected health information may be disclosed or used for treatment, payment, or health care operations.
We have a Notice of Private Practice and you have the right to review a detailed copy of our Notice before signing this HIPAA Patient Consent.
We reserve the right to change the terms of our Notice of Private Practices
If we change our Notice, you may obtain a revised copy by contacting our office.
You have the right to restrict the uses of your protected health information.
You may revoke this HIPAA Consent in writing at any time. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent.
By signing the next page of this document, you certify that you have read our HIPAA Patient Consent and have had the opportunity to review a more detailed version if so desired. Your signature also signifies that you agree with the above statements and this policy. You also agree to authorize the release of medical information to your primary care or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. We provide this form and information in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I have reviewed and reinstate my general authorizations to release or obtain records. I have reviewed my registration information including Medical History information and it is complete and correct
I authorize the duly licensed physicians (MD, DO) and nurses (ARNP) and physician assistants (PA employed by Concierge Health & Rejuvenation Solutions to provide medical / cosmetic/ aesthetic care services to me. I understand that this may or may not include medical evaluation and treatment, minor surgical procedure including, but not limited to, biopsy (obtaining sample of tissue) and debridement (removal of tissue interfering with wound healing),injections, ordering of medications and supplies, and ordering or performing diagnostic or therapeutic procedures, and to administer any and all treatment that the Medical Provider or Staff deem necessary.
PHOTOGRAPHY / VIDEO CONSENT

I authorize the use of IF APPLICABLE, PRE & POST PROCEDURE photos and/or videos for teaching and publication AFTER sanitized of identifying information.
MOBILE PHONE /TELEPHONE MESSAGES/TEXTS CONSENT *

I hereby authorize Concierge Health & Rejuvenation Solutions, LLC to contact me by Cell / Telephone /Text and, if I am not present, to leave a message on my answering machine and/or voicemail and/or text message or DM me □ I prefer that Concierge Health & Rejuvenation Solutions, LLC NOT leave messages on my answering machine □ I authorize Concierge Health & Rejuvenation Solutions, LLC, and its affiliated companies to send me text messages regarding my account and about their products, services, and promotions, using automatic telephone dialing system. I understand that I am not required to check this box as a condition of purchasing any property, good, or service, (If I receive a text message, I can reply HELP for help or reply STOP to withdraw consent, Message and date rates may apply)
The following people, other than a duly designated guardian, conservator or healthcare surrogate are authorized to receive information regarding my medical condition and/or billing information
*

I attest that the above (and all previous pages) information is correct to the best of my knowledge.
*

 My printed name & signature below certify that I have provided complete and accurate contact &medical information  I have read, fully understand & completely agree with the Patient Consent, HIPAA, Financial Responsibility Policy, Missed / Late Appointment Policy, Consent for Photography / Video, contained in this document and  I agree to Examination and Treatment.
Signature *

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General Patient Information

General Patient Information

Patient Medical History

Healthy & Unhealthy Habits