Windermere Medical Spa & Laser Institute New Patient Paperwork

1
Name* This field is required.
First Name
Last Name
2
Date* This field is required.
Date
Month
Day
Year
3
Phone Number* This field is required.
Area Code
Phone Number
4
Email* This field is required.
example@example.com
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Date of Birth* This field is required.
Date
Month
Day
Year
7
Emergency Contact: First Name *     Last Name *
Relationship:
Phone Number: *
8
When confirming appointments how do you prefer to be contacted?* This field is required.
Phone
Email
Text Message
9
How did you hear about our office? (Check All That Apply)* This field is required.
Social Media
Mail
Google
Website
Flyer
Drive By
Brochure
Friend or Patient
10
If you chose "Friend or Patient", please let us know who:Friend of Patient must be named on paperwork to give referral credit.
11
Preferred Pharmacy:
Pharmacy Phone Number:
Pharmacy Address:
Primary Care Physician: Office Phone:
12
Are you currently under medical treatment?* This field is required.
No
Yes
13
If you selected "YES", please explain:
14
Have you ever been hospitalized for any surgical operations (including plastic surgery) or serious illnesses within the last 5 years?* This field is required.
No
Yes
15
If you selected "YES", please explain:
16
Are you taking any medication(s) including non-prescription medicine?* This field is required.
No
Yes
17
If you selected "YES", please explain:
18
Do you use Tobacco?* This field is required.
No
Yes
19
Do you use controlled substances or recreational drugs?* This field is required.
No
Yes
20
How often do you drink alcohol?* This field is required.
Never
Socially
Frequently
21
What is your daily consumption of alcohol?* This field is required.
22
Are you ALLERGIC to any medications?* This field is required.
No
Yes
23
If you selected "YES", please explain:
24
Do you have any allergies?* This field is required.
YESNO
25
Please list any additional ALLERGIES you have:
Huge
Large
Normal
Small
Ok
Ok
26
Are you pregnant?* This field is required.
No
Yes
27
If you selected "YES", how many weeks?
28
Are you taking contraceptives or hormones?* This field is required.
No
Yes
29
If you selected "YES", which kind?
30
Are you Nursing?* This field is required.
No
Yes
31
Have you reached Menopause?* This field is required.
No
Yes
32
Have you ever had a reaction to any of the following?* This field is required.
Local anesthetics
Aspirin, Acetaminophen, or Ibuprofen
Antibiotics
Reaction to metals
Sulfa drugs
Latex or Rubber
Barbiturates or sleeping pills
Codeine, Demerol, or other narcotics
Other
NONE - Never had a reaction to anything
33
You selected "Other", please list what you have had a reaction to:
34
Have you ever had to use an epi pen* This field is required.
No
Yes
35
If yes, please elaborate as to why
36
Do you have a history of anaphylaxis?* This field is required.
No
Yes
37
Do you have, or have you had any of the following? (Please check all that apply)* This field is required.
Heart Problems
Chest Pain
Blood Pressure Problems
Heart Murmur
Skin Rashes
Asthma
Stroke
Headaches/Migraines
History of Head Injury
Intestinal Problems
Thyroid Problems
Epilepsy or other Neurological Disease
Weight Gain/Loss
Persistent cough or swollen glands
Psychological Treatment
Rheumatic Fever
Constipation/Diarrhea
Cancer/Tumor
Vitiligo
Pacemaker
Artificial Heart Valve
Kidney or Bladder Problems
Diabetes
Auto-Immune Disease
Bruises Easily
Arthritis
Hepatitis, Jaundice, or Liver Trouble
Skin Diseases/Skin Cancer
Frequent Nosebleeds
Back or Neck Pain
Herpes Virus
Anemia
Any active infection
STD
Keloid Scarring
Allergy Problems
Joint Replacement
HIV-Positive/AIDS
Alcoholism
Hormone Imbalance
Fainting, Seizures, or Epilespy
Glaucoma
Sinus Problems
Seizure Disorder
Other
38
Please Note the Skin Diseases/Skin Cancer(s):
39
Please Note the STD(s):
40
Have you ever had any medical aesthetic treatments? * This field is required.
YESNO
41
Please list your prior medical aesthetic treatments & when you received them
Huge
Large
Normal
Small
Ok
Ok
42
Have you ever had Botox Fillers Facial Lasers ?
If so, when?
43
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? NO YES
If "YES", please describe
44
How often are you exposed to the sun?
Infrequently Regularly *
45
What skin care products are you currently using?* This field is required.
46
What is your skin type?* This field is required.
Normal
Oily
Dry
Sensitive
47
Have you been treated with Accutane?
No
Yes, last treatment:
48
What are you interested in treating? (please check all that apply):
Acne
Lips
Facial Balancing
Cheeks
Wrinkles
Under Eyes/Dark Circles
Milia/Whiteheads
Chin
Brown Spots
Jawline Contouring/Jaw Reduction
Redness
Temples
Rosacea
Non-Surgical Rhinoplasty
Scars
Hand Rejuvenation
Sagging/Loose Skin
TMJ/Grinding
Eyebrow Lift
Gummy Smile
Skin Texture
Non-Surgical Butt Lift
Stretch Marks
Cellulite
Veins
Hair Restoration
Other
49
What services would you like to know more about? (please check all that apply):
Botox/Dysport for Wrinkles
The Signature MK Pout
PDO Thread Lift
BBL Corrective & Forever Young
Sculptra Face & Body
Dermal Fillers
Radio Frequency Microneedling
Laser Treatments
Scar Therapy
DiamondGlow
AquaGold
Microneedling
TMJ Remedy
Laser Hair Removal
Acne Injections
Dermaplaning
PRP
Chemical Peel
B12/Fat Burner Injection
Cosmelan
LED Therapy
Tixel
Beauty Bank Membership
Other
50
Are you interested in Dental Services?We offer both Cosmetic & Full Family Dentistry
YESNO
51
What dental services are you interested in?
Teeth Whitening
Invisalign
Veneers
Crowns
Dental Cleaning
Fillings
Other
52
53
Please initial below to agree to our Medical Spa Policy* This field is required.
54
Medical Spa Policy* This field is required.BY BOOKING AN APPOINTMENT YOU ACKNOWLEDGE THAT YOU HAVE READ & AGREE TO ALL OF OUR POLICIES AND PROCEDURES. All prices, policies and services are subject to change without notice. Deposits: A non-refundable $100.00 deposit is required to reserve each appointment. Some services may require a larger deposit. Your card on file will be charged within 24-48 hours of booking an appointment. If you choose to receive treatment or pre-pay for your treatment during this visit, your non-refundable deposit will be applied to your total balance. For consultations: if you choose to not receive treatment at the time of your appointment, your deposit will be applied as a consultation fee. Beauty Bank members will not be required to place deposits (unless they violate the BB policies as outlined in the agreement). Please refer to the Beauty Bank Agreement for the full terms & conditions. Cancellation/Reschedule/Late/ No-Show Policy: We require clients to provide us with at least 48 hours’ notice (within business hours) if you are unable to keep the time we have reserved for your appointment. Any cancellation/no- show or rescheduling less than 48 hours prior to your appointment will result in a cancellation fee of $100.00 or $200.00, depending on the appointment type/amount of offenses.* IF YOU NO-SHOW AN APPOINTMENT, YOU WILL BE REQUIRED TO PLACE A $200 NON-REFUNDABLE DEPOSIT TO REBOOK, IN ADDITION TO PLACING 2 CARDS ON FILE. Patients who no call, no-show for appointments will be required to put a $200.00 deposit for ALL future appointments. If you are more than 15 minutes late for your service, we may not be able to accommodate you. In this case, the same cancellation fee will apply. NO CALL, NO SHOW / LATE CANCEL FEES BY APPOINTMENT TYPE: • $100 Fee – Botox, Dysport, DiamondGlow, Hollywood Laser, BareIT (Single Area) • $200 Fee – Filler, Sculptra (Face/Body), Lasers (Total Skin Solution, LaseMD Ultra, BBL, HALO, BareIT (Full Body), Tixel, Profractional), Subnovii BB Members: for no-show or late cancel/reschedule you forfeit the ability to schedule appointments without a deposit and will be required to either place a deposit or use BB funds to secure appointments. Beauty Bank members will be held to the same deposit fee as listed above and fees for No Call/No Show or Late Cancel. Financial Responsibility: As a client of Windermere Dental & Medical Spa, you understand that you are responsible to pay in full at the time any service is rendered. We accept most major credit or debit cards: VISA, MasterCard, Discover & American Express and Care Credit. We do not accept checks or insurance. We require you to maintain an active credit/debit card on file. BB Members must update their card on within 10 days if your card is to change. ALL SALES ARE FINAL. We do not offer refunds on any used or unused procedures, service packages or series. Products may be returned for in-store credit within 7 days. The prices on your customized treatment program will be valid for 1 month (30 days). Prices are subject to change after 30 days. Time-sensitive promotions may end prior to the 30-day window. To guarantee the price, you may pay 50% in advance for any procedures. All sales are final and cannot be refunded. All pre-purchased or banked services must be used within 1 year from purchase date. If you have received treatments from your package and choose to break up the package, the treatments received will revert to full price and the difference will be credited to your account. The remaining funds will be available to use toward other services and products at Windermere Dental & Medical Spa. We require that all services sold in packages be used within 1 year of purchase date. Communications: By joining our practice as a patient, you are consenting to receive emails or text messages from us pertaining to your appointments and promotional materials. Please note that you retain the freedom to unsubscribe from these communications at any time.
Clear
55
Authorization and Release: I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize Windermere Dental & Medical Spa to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such care to third party payors and/or health practitioners. I agree to be responsible for payment of all service rendered on behalf of myself and/or on the behalf of my dependents.
56
Medical Spa Policy* This field is required.
57
HIPAA* This field is required.THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMTION. PLEASE REVIEW IT CAREFULLY. This notice of Privacy Practices describes how we may use and disclose your protected health/personal information (PHI) to carryout out treatment, payment or business operations (TPO) and for other purposes that are or required by law. It also describes our rights to access and control your protected information. Protected health/personal information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. 1. Uses and Disclosures of Protected Health/Personal Information Your protected health/personal information may be used and disclosed by our medical director, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you to support business operations of this office, if requested to you by a finance company to pay for your care, and any other use required by law. Treatment: We will use and disclose your protected health/personal information to provide, coordinate, or manage your health care and any reacted services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health/personal information, as necessary, if, as a result or our services, you require treatment by a physician. Your protected health/personal information may be provided to a physician to whom you have been referred to ensure that the physician has necessary information to diagnose or treat you. Payment: Your protected health/personal information will be used, if requested, to obtain payment for your services. For example, if you desire to finance the costs of your treatments, this may involve disclosing relevant protected private information in order to obtain approval. Healthcare Operations: we may use or disclose, as needed, your protected health/personal information in order to support the business activities of this office. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. In addition, we may use a sign-in sheet the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when we are ready to see you. We may use or disclose your protected health/personal information, as necessary, to contact you to remind you of your appointment. We may use or disclose your protected health/personal information in the following situations without your authorization. These situations include: as required by law; public health issues as required by law, communicable diseases; health oversight; abuse or neglect; Food and Drug Administration requirements; legal proceedings; law enforcement; inmates; required uses and disclosures. Under the law, we must make disclosure to you and, when required by the Secretary of the Department of Health and Human Services, to investigate or determine our compliance with the requirements of Section 164.500. Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that this office has taken an action in reliance on the use or disclosure indicated in the authorization. 2. Your Rights Following is a statement of your rights with respect to your protected health/personal information. You have the right to inspect and copy your protected health/personal information. Under federal law, however, you may not inspect or copy the following records: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health/personal information that is subject to law that prohibits access to protected health/personal information. You have the right to require a restriction of your protected health/personal information. This means you may ask us not to use or disclose any part of your health/personal information for the purposes of treatment or healthcare operations. You may also request that ant part of your protected health/personal information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree a restriction that you may request. If our medical director believes it is in your best interest to permit use and disclosure of your protected health/personal information, your protected health/personal information will not be restricted. You then have the right to use another service provider. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e., electronically. You may have the right to amend your protected health/personal information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to our statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, of any, of your protected health/personal information. We reserve the right to change this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. This notice was published and becomes effective on/or before September 14, 2017. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health/personal information. If you have any objections to this form, please ask to speak without HIPPA Compliance Officer in person or by phone at our Main Phone Number. The Heath Insurance Portability and Accountability Act (HIPPA) provides safeguards to protect your privacy. To comply with HIPPA regulations, we must obtain your permission to share your protected health information with any other patients with comprehensive care, and as such, we request your consent to disclose your protected health information to Windermere Dental for the purposes of providing certain services, treatment, for billing purposes, and for healthcare operations. You understand and agree to the following: • Your protected health information may be disclosed to or used by Windermere Dental and Windermere Medical Spa for services, treatment, billing, or healthcare operations. • Your protected health information will not be disclosed to any other entity or person unless we are specifically authorized to do so under the law or by written statement from you. • We may condition receipt of treatment upon the execution of this consent. • You have the right to receive a copy of this consent. • Windermere Dental and Windermere Medical Spa will not further use or disclose the medical information to any other person unless you specifically request the disclosure, or the disclosure is required or permitted by law. • This Consent to share your information shall be valid for one year from the date of this Consent. • You may revoke this Consent in writing at any time and all future discoveries to Windermere dental and Windermere Medical Spa will then cease. However, such a revocation shall not affect and disclosures we have already made in reliance on your prior Consent. • You understand that if you choose to revoke your consent, you will still be able to receive any services or treatments that you have already paid for or are in the process of receiving, as long as this information is not needed to provide those services or treatments By signing this form, you acknowledge and certify that you have read and understand the “consent, release and indemnity agreement,” you also voluntarily consent to our use and disclosure of your protected health information to Windermere Dental and Windermere Medical Spa in the manner, term, and purposes identified above.
58
Signature* This field is required.Authorization and Release: I certify that I have read and understood the information on this form to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize Windermere Dental & Medical Spa to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such care to third party payors and/or health practitioners. I agree to be responsible for payment of all service rendered on behalf of myself and/or on the behalf of my dependents. I have read and agree to the policies outlined.
ClearPlease provide signature
59
CONSENT TO SHARE PROTECTED HEALTH INFORMATION* This field is required.
60
Tags
Todo
In Progress
Done
Should be Empty: