Patient Paperwork

Welcome to Oregon Derma Center

Thank you for selecting our practice! So that we may best serve you, please fill out this form as accurately as possible and submit. If you have any questions or need assistance, please call us - we are happy to help. Thank you.
Patient Information
Name*
First Middle Last
Date of birth*
Date Format: MM slash DD slash YYYY
Gender*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Legal status
Are you a student?
If yes, what school do you attend?
Contact Information
Email*
Phone*
Would you like an appointment reminder call?
Emergency Contact
Person to contact in case of EMERGENCY:
Phone Number:
Relationship to patient:
How did you hear about Oregon Derma Center?
How did you hear about us?

Daily fluid Intake:
Have you had recent exposure to the sun ?
If Yes, How long
On a scale to 1 - 5 how frequently are you in the sun?
If Yes, when was the last time?
do you use tanning beds?
If Yes, which one and when was the last time?
do you use self tanner?
do you use sun screen daily?
If Yes, what brand?
Which of the fallowing describes your skin?
Have you used any of the fallowing medications?
- Retin-A
- Accutane
- Benzoyl peroxide
- Retinoids
- Salicylic acid
- Glycolic acid
- Other
Please describe Your skin care routine including products:

Primary care Clinic/Location
Primary care Psychical:
Have you ever undergone a cosmetic procedure?
If Yes, what Type?
were you satisfied? (what did you like/dislike)
reasons for your visit today? (please describe your expectations)
On a scale 1 - 5 how satisfied are you with your life? (personal or professional 5 being most satisfied) )
Additional services you would be interested in?
By signing below, i acknowledge that the information on pages 1-3 has been completed and is accurate to the best of my knowledge.
Today's Date:

Legal Age and Disclosure of Medical History
I certify that I am a competent adult of at least 18 years of age. If the patient is not of legal age, the undersigned certifies that I am the patient's custodial parent or legal guardian and that I have full power and authority to consent to the treatment on behalf of the minor patient. I will disclose a full and accurate personal medical history, including any and all information regarding medical conditions and use of medications, drugs, herbs, vitamins, or other supplements of any kind. I understand that failure to do so may affect my treatment outcome and increase the likelihood or severity of side effects or complications
Consent to treatments
Understand and agree that I am consenting to receive a cosmetic treatment or service. This is strictly a voluntary cosmetic procedure. No treatment or service is necessary or required. The risks and complications associated with treatments or services and various alternatives have been explained to me by the Oregon Derma Center staff. I freely and voluntarily agree to undergo the treatment or service. I understand that the Oregon Derma Center services generally consist of a series of treatments and services to achieve maximum benefit and this consent shall apply to all services rendered to me by the Oregon Derma Center, including ongoing or intermittent treatments.
No Guarantee
I UNDERSTAND THAT NO GUARANTEE HAS BEEN GIVEN AS TO THE RESULTS THAT MAY BE OBTAINED BY ANY OF THE SERVICES OR TREATMENTS OFFERED BY THE OREGON DERMA CENTER. Best efforts will be made to deliver excellent results and it is understood that patient compliance with recommendations is critical for optimal outcomes

Financial Responsibility for Treatment
please Initial next to each line
I understand that aesthetic treatments or services are not medically necessary, and are therefore not covered by any insurance or other third party payer program. I understand that I am fully responsible to pay for all of the services rendered to me.*
In some instances, a pre-paid package of services may be purchased at a discount off of customary rates. As a condition of receipt of the discounted rate, I acknowledge and agree that packages of pre-paid services and treatments are non-refundable for any reason.*
I understand that all services, including prepaid services, are non-refundable. I will not be entitled to a refund if I am not satisfied with the results of treatment, on account of a delay in treatment, if I relocate from the area, or for any other reason whatsoever.*
I understand that if the procedure takes longer than the customary time, Oregon Derma Center reserves the right to charge an additional fee for each additional half hour.

Payment Information
Payment today will be made with:
Signature of patient or parent if minor or responsible party
Today's Date

Scheduling and Cancellations
While Oregon Derma Center will strive to schedule and provide treatments during Oregon Derma Center's normal business hours and at such times as I may reasonably request, Oregon Derma Center cannot guarantee against delays in treatment due to scheduling conflicts for Oregon Derma Center personnel, maintenance to medical equipment, or any other foreseen or unforeseen causes. If you cannot keep your appointment, please cancel as soon as possible. In order to assure our patients the highest level of service, we require a 48-hour cancellation notice. If such courtesy notice is not given, a $50 charge will apply for appointments with the medical aesthetician/assistant and $100 will apply for appointments with the doctor. All patients who do not give such notice will have to put a deposit toward their next appointment, which is forfeited if the "no show" recurs. Failure to show for treatments that require an hour or more of staff time or special preparation will be charged at the full value. Failure to show or cancel 48 hours in advance for a treatment that is part of a package will result in forfeiting of that session. Please plan on arriving about 10-minutes before your scheduled time to allow for unforeseen delays, such as traffic, parking or paperwork. Arriving 15-minutes or more late for an appointment may result in the need to reschedule or shorten your appointment time accordingly.
Signature of patient or parent if minor or responsible party
Today's Date

Acknowledge and consent to treatment (To be signed after the consult)
Thereby acknowledge that I have read and understand all of the information presented to me before signing this acknowledgement and consent that the benefits and risks as well as the alternatives to the treatments or services have been fully explained to me and all questions that I might have about the treatments or services have been answered in a satisfactory manner. I hereby give unrestricted informed consent to receive the treatment and services. This acknowledgement and consent shall apply to all services rendered to me by the Oregon Derma Center staff, including ongoing or intermittent treatments. I accept full financial responsibility for this treatment and all subsequent treatments. I further agree, in the event of non-payment, to bear the cost of collection, including court costs and attorneys' fees, should this ever be required.
By signing below, I acknowledge that the information on page 1-7 has been completed and is accurate to the best of my knowledge.
Patient Printed name:
Today's Date

Step 1 of 9

Patient Information

Contact Information

Emergency Contact

How did you hear about Oregon Derma Center?

Medical History

Legal Age and Disclosure of Medical History

Consent to treatments

No Guarantee

Financial Responsibility for Treatment

Payment Information

Scheduling and Cancellations

Acknowledge and consent to treatment (To be signed after the consult)