Colorado Aesthetic Center 9320 Grand Cordera Parkway , Suite #250 Colorado Springs, CO 719.387.7800 Skin and Health Questionnaire Please answer the following questions thoroughly and completely, as this provides a better understanding of your general health, lifestyle and skin care concerns; thereby enabling the best treatment and home care recommendations. Name: DOB: ---------------------- Address: ______________________________________________________________ _ Occupation: Email:. ____________________ _ Cell Phone: Alternative Phone: ______________ _ Let us thank the person who referred you: - ----------------------------------- Please tell us your main areas of concern: ------------------------------------- What are the Services & Products you are interested in : Genesis Laser __ Limelight Laser Laser Hair Reduction Pearl Laser Microdermabrassion Botox Latisse Neova Skin Care History Chemical Peels Radiesse iS Clinical Titan Laser __ Oermaplane Facial Juvederm __ Epionce Skin Care If there was something you could change or improve about your skin, what would it be? What else? Please check all that apply: __ Discoloration __ Acne Scarring (brown spots or melasma) _ _ Enlarged Pores __ Fine lines & Wrinkles __ Rosacea _ _ Dry, Flaky skin __ Dilated Capillaries __ Oily skin __ Redness Acne I Breakouts (Reactive Skin) What type of skin do you think you have? __ Dry _ _ Normal __ Combination If oily, are you oily throughout the cheek area? Yes__ No Do you have history of Acne? Yes No Uneven Texture __ Sun Damage Loss facial contours _ _ Lax or sagging skin __ Dark Under-eye circles Oily
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Colorado Aesthetic Center 9320 Grand Cordera Parkway , Suite #250
Colorado Springs, CO 719.387.7800
Skin and Health Questionnaire Please answer the following questions thoroughly and completely, as this provides a better understanding of your general health, lifestyle and skin care concerns; thereby enabling the best treatment and home care recommendations.
Name: DOB: ----------------------Address: ______________________________________________________________ _ Occupation: Email:. ____________________ _ Cell Phone: Alternative Phone: ______________ _ Let us thank the person who referred you : - ----------------------------------Please tell us your main areas of concern: -------------------------------------
What are the Services & Products you are interested in : Genesis Laser __ Limelight Laser Laser Hair Reduction Pearl Laser Microdermabrassion Bot ox Latisse Neova
Skin Care History
Chemical Peels Radiesse iS Clinical
Titan Laser __ Oermaplane
Facial Juvederm
__ Epionce Skin Care
If there was something you could change or improve about your skin, what would it be?
What else? Please check all that apply: __ Discoloration __ Acne Scarring (brown spots or melasma) _ _ Enlarged Pores __ Fine lines & Wrinkles __ Rosacea _ _ Dry, Flaky skin __ Dilated Capillaries __ Oily skin __ Redness
Acne I Breakouts (Reactive Skin)
What type of skin do you think you have? __ Dry _ _ Normal __ Combination
If oily, are you oily throughout the cheek area? Yes__ No
Do you have history of Acne? Yes No
Uneven Texture __ Sun Damage
Loss facial contours _ _ Lax or sagging skin __ Dark Under-eye circles
Oily
If yes, are you using or have you ever used any medications for Acne? Yes __ No __
Name of Medication ________________________ _
Do you sunbathe or participate in outdoor activities? Yes__ No Have you ever had reaction to any skin care products or cosmetics? Yes__ No
If yes, please list----------------------------
What skincare do you currently use? Cleanser Toner _______ _ Mask _______ _ Moisturizer ______ _ Sunscreen ______ _ Scrub _______ _
Night Cream------- Eye cream ------- Serum --------
Please check if you are currently using or have used any of the following : Retinol __ Benzoyl Peroxide __ Adapelene (Differen)
Have you ever, or are you currently receiving skin treatments? Yes No
Please check the following conditions you have, or have had, in the treatment area: Dermatitis __ Cold Sores I Fever Blisters Eczema Psoriasis
__ Open sores or lesion
Are you allergic to aspirin?
Actinic Keratoses __ Keloid Scarring
Yes
If you have any known allergies, please list them:
Have you had any of the following? __ Chemical Peel __ Permanent Cosmetics __ Laser Resurfacing __ Light Treatments __ Derma planing __ Waxing
Microdermbrasion __ Faciallnjectables
No
Extractions __ Electrolysis
Laser Hair Removal __ Facial Cosmetic Surgery
If yes, when was your last treatment?--------------------
Were there any complications? Yes No
If yes, please explain--------------------------
General Health Are you currently under the care of a physician? Yes__ No If yes, please discuss contra indications of any pre-existing medical conditions with your physician.
Are you currently taking any medications?
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Yes No
Female Clients Are you on hormone- replacement therapy? Are you currently taking birth control pills? Are you pregnant or breast feeding?
Please check any health problems, past or present : __ Seizures __ Hormonal Problems __ Vasovagal Syncope __ Liver Disease
Heart Problems PCOS __ Cystic Acne
Sarcoidosis __ Hepatitis
__ Autoimmune (LUPUS) Asthma Scleroderma
Yes Yes Yes
No No No
__ High Blood Pressure Diabetes
__ Skin Cancer (type_) __ Thyroid __ Cancer (type __ )
Is there anything else that should be known before starting your treatment?
Colorado Aesthetic Center 9320 Grand Cordera Parkway , Suite #250
Colorado Springs, CO 719.387.7800
Permission for use of Photographs
I hereby give Colorado Aesthetic Center permission to use my photographs in the following manner: _____ use only photos in which my identity is concealed _____ unrestricted use of photographs (this may include web site) _____ use in the physician's office to show other patients "before/after" pictures _____ use in the physician's new patient seminars to teach other patients about procedures _____ use for medical education/lectures to other physicians _____ use in professional writing which may include textbooks, journals, newsletters
The specific restrictions on the use of my photographs include:
I understand that this consent may be revoked in writing but not by implication.
HIPPA AGREEMENT THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice of privacy describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your right to access and control your protected health information. Protected health 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 condition and related health care services.
Use and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care service to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.
Treatment: We may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services and insurance. We may use or disclose, as needed, information about you to such insurers or other business associates to obtain these services.
We may use or disclose your protected health 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, Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activity and national Security, Workers' Compensation, Inmates Required Uses and Disclosures. Under the law we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with 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 your physician
or physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Your Rights The Healthcare record we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. Following is a statement of your rights with the respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information. This means you may ask us to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not to 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. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Health Care Professional.
You have the right to request 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.
You may have the right to have your physician amend your protected health 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 your statement and will provide you with a copy of such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of 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 file a complaint with us by notifying our privacy contact of your complaint. You may also contact the secretary of Health and Human Services if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint. This notice was published and becomes effective on/or before July 1, 2007.
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 information. If you have any objections or questions to this form, please ask to speak with our HIPP A Compliance Officer in person or by phone. Signature below is only acknowledgement that you have received this Notice of Privacy Practices:
Printed Name -------------------------Signature---------- -------Date ----------------
