Aesthetic Services - New Patient Forms

Aesthetics Services - New Patient Forms
PLEASE NOTE THIS FORM MAY NOT LET YOU SIGN IN MOBILE VERSION ON A CELL PHONE- YOU MAY NEED TO VIEW IN DESKTOP VERSION ON YOUR PHONE OR USE LAPTOP TABLET OR PC

Hello!

Thank you for scheduling your first visit for Aesthetics (botox/juvederm) at HorizonView Health! If you have any questions please call us at 253-268-3345

Thank you so much!

HorizonView Health staff
Welcome to HorizonView Health!

Thank you for scheduling an appointment at our office, we are happy you have found your way to us!

Please check-in 15 minutes prior to your scheduled appointment time. If you arrive late for your check-in time you may be asked to reschedule.

Our Address is:

1408 3rd St SE Suite 200 Puyallup, WA 98372

Ph: 253-268-3345 Fax: 253-881-1490

We are located across the street from Good Samaritan Hospital Emergency Room entrance and down one building. Covered/additional parking is available under the building for your convenience.

Please bring with you:

· Your picture ID

· Your payment for the services provided (the $50 pre-payment will be subtracted from the full amount owed and any Alle' points/deals/discounts will be subtracted upon check-out)

Note: We only accept debit/credit cards or check.

We unfortunately are unable to accept cash, We apologize for this inconvenience.

If you are unable to keep your appointment, please call us at 253-268-3345

Sincerely,

HorizonView Health Staff

A map of our location is located on our website.
Patient Intake Form

Patient Information:
Patient Legal Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Legal Gender*

FemaleMale
Preferred Name
Patient Race*
Hispanic Ethnicity?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*
Please enter a valid phone number.
Alternative Phone
Please enter a valid phone number.
Ok to leave detailed message?*

YesNo
Email*
example@example.com
Are you currently a patient at HorizonView Health?

YesNo
How did you hear about us?
Emergency Contacts
Name*

First NameLast Name
Relationship *
Phone Number*
Please enter a valid phone number.
Notify on Hospital Admission*

YesNo
Secondary Emergency Contact (if applicable)
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Medical History
Medical Conditions*

Artifical Joints/ImplantsAsthmaBlood Clots/ Bleeding DisorderBreast CancerCancerChest PainChemical/Radiation TherapyDefibrillatorDiabetesEye ProblemsHeart DiseaseHeart MurmurHepatitisNoneOther
Skin History*

NoneAcneDry SkinEczemaHives or ItchingInfection of the SkinKeratosisMelanomaMolesPsoriasisRashesScarsOther
Patient Past Surgeries/Hospitalizations*

Cardiac SurgeryJoint ReplacementImplant SurgeryCosmetic SurgeryNoneOther
Relevant Family History*

AllergiesAutoimmune DisordersBreast CancerBRCA positiveDiabetesHeart DiseaseHigh Blood PressureHemophiliaNoneOther
Social History
Tobacco History:*

No history of tobacco useCigarettesCigarPipeChewVapor
If yes,
# Years using:   Type a label
Packs/Day:   Type a label
If quit, how long ago?   Type a label
Alcohol Use:*

No alcohol useAlcohol use rarelyAlcohol use sociallyAlcohol use daily
Recreational Drug Use:*

NoYesPast
Marijuana Use:*

NoYes
Primary concerns for today's consult or treatment:*
What are your expectations for today's visit?
Have you addressed your concerns with a physician or aesthetician prior to today's treatment?

YesNo
Please Indicate the following skin concerns: (Select all that apply)*

AcneBroken Blood VesselsBrown SpotsCrows FeetFacial DrynessFacial OilinessFacial Volume LossForehead Lines/Frown LinesLip LinesLip Volume LossNeck and Chest DiscolorationNose-to-Mouth LinesSpots/FlushingScarringSkin TextureThin, Short or Lightened LashesUnder Eye Circles/Crepiness or CrepingUneven Skin TextureUnwanted HairNoneOther
Please Indicate the following services that interest you: (Select all that apply)

BOTOX CosmeticsFacial Injectables/ Dermal FillersGeneral Skin Health/ Product AdviceOther
When was the last time you received a cosmetic consult or facial service?
Type of service received:*

BotoxChemical PeelCosmetic ConsultDermal FillerFacialLaser TreatmentWaxingN/A
Please describe any adverse reactions to previous cosmetic treatments:
Please list any allergies:
Current medications:*
Are you currently using any for of:*

Retin-ADifferinTazoracRenovaGlycolic AcidSalicylic AcidHydroquinoneNoneOther
Have you ever been on Accutane?   Yes   No*
Date of last treatment:

Are you pregnant or lactating (breastfeeding)?   Yes   No*

Do you have a history of herpes simplex (cold sores)?   Yes   No*

Do you currently take an anti-viral medication for the prevention of treatment of cold sores?    Yes   No*

Do you have a history of Lupus or any other auto-immune disease?   Yes   No*

Have you ever developed keloids (raised scars)?     Yes   No*

Do you tan on a regular basis?    Yes   No*

Do you have a history of atypical moles, Melanoma or skin cancer in your family?   Yes   No*

Do you have any history of trauma to the head or face?   Yes   No*

Do you have any history of facial surgery?   Yes   No*

Please describe any adverse reactions to topical skin care products, makeup and medications:   Type a label
Alle (Formally Brilliant Distinctions)
Are you currently enrolled in AlleProgram?*

YesNo
If yes, please provide us with your member number (phone number):
If not, Alle is a program that rewards you with savings on Allergan facial treatments and products, like Botox and Juvederm. Ask us for details on how to sign up!
Aesthetic services No-Show/Cancellation Policy
We, at HorizonView Health, understand that sometimes you need to cancel or reschedule your appointment and that there are emergencies. If you are unable to keep your appointment, please call us as soon as possible (with at least 24-hour notice). You can cancel appointments by calling us at 253-268-3345. To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. As a courtesy, an appointment reminder call is attempted two (2) business days prior to your scheduled appointment. However, it is the responsibility of the patient to arrive for their appointment on time.
We ask that you cancel your appointment with at least 24 hours' notice so your appointment time can be offered to other patients. If less than a 24-hour cancellation is given, this will be documented as a "No-Show" appointment. If you do not show up to your scheduled appointment, your $50 deposit that is paid at the time of scheduling will be forfeit and the pre-payment will not be able to be applied to any future visits.
Please Note: Your $50 pre-payment will go toward your services, if you do keep your appointment.
I have read and understand the Cancellation Policy Acknowledgement.
Signature*

Clear
Date*

MonthDayYear
Date
Notice of Privacy Practices
The practice of HorizonView Health is required by applicable federal and state laws to maintain the privacy of your health information. Protected health information (PHI) is the information we create and maintain in the course of providing our services to you. Such information may include documentation of your symptoms, examination and test results, diagnoses and treatment protocols. It also may include billing documents for those services. We are permitted by federal privacy law (the Health Insurance Portability & Accountability Act of 1996 (HIPAA), to use and disclose your PHI, without your written authorization, for purposes of treatment, payment, and health care operations.

I have read and understand the HIPAA acknowledgement.
Signature*

Clear
Date*

MonthDayYear
Date
Aesthetics Financial Policy
As patients contemplate aesthetic treatments, they frequently need information about the financial aspects of their treatment and the various payment methods available to them. Our staff members are specially trained in the financial options available to our patients, and they are readily available to answer your questions. Because we provide elective cosmetic procedures, the care provided at HorizonView Health is not covered by any medical insurance programs, and we do not participate in any such plans.

Payment for all aesthetic procedures is due at the time of the treatment. For specially packaged or grouped treatments, payment for the entire package is due at the time of the first scheduled treatment. We provide several payment options which may be used individually or combined.

If a treatment, package, or series of treatments has been purchased, begun treatment or not, these services will be considered to have been rendered even though the full series may not have been completed. Should you wish to discontinue your treatment during a series, credit for the pro-rated share of unused treatments at the discounted package price may be extended and may be used to purchase other treatments or products offered by HorizonView Health. Any credits accrued may not be transferred to another individual to be used in exchange for treatments or products of comparable value. HorizonView Health has a no refund policy.

I have read and understand the Financial Policy Acknowledgement.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Aesthetics Services - New Patient Forms

Patient Intake Form

Emergency Contacts

Secondary Emergency Contact (if applicable)

Medical History

Social History

Alle (Formally Brilliant Distinctions)

Aesthetic services No-Show/Cancellation Policy

Notice of Privacy Practices

Aesthetics Financial Policy