Patient Paperwork Patient Paperwork Step 1 of 9 11% 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 InformationName* First Middle Last Date of birth* MM slash DD slash YYYY Gender*Choose oneMaleFemaleOtherMailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Legal statusChoose OneMinorSingleMarries / Domestic PartnershipDivorced / SperatedWidowedAre you a student?Please SelectYesNoIf yes, what school do you attend? Contact InformationEmail* Phone*Would you like an appointment reminder call?Please selectYesNoEmergency ContactPerson 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?Please SelectDr. Jason BlackInternet | GoogleNewsletter | BlogOpen HouseSocial MediaAdvertisement | Billboard Medical HistoryPatient Name: Date of birth Age Ethnic Background African American Caucasain Hispanic/latino Indian Native American other which on of the following best describes your skin?Highly sun sensitive, always burns, never tansvery sun sensitive, easily burns, minimally tanssun sensitive skin, sometimes burns, slowly tansminimally sun sensitive minimal burns, tans to light brownsun insensitive skin, rarely burns, tans wellsun insensitive, never burns, deeply pigmentedDo you take any medication, herbal/ natural supplements or topical treatments on a regular or daily basisyesnoIf Yes, please explain Do you have any allergies to medication, food latex or other substances.YesNoIf Yes, please explain Do you have a history with any of the following conditions? Syphilis Hepatitis HIV/AIDS Psychiatric problems Herpes simplex Smoking Alcohol Please check the following if you have a HIstory of: Cold sores Fever blisters Herpes Simplex If Yes, please explain any suppression mediation and last outbreak: do you exercise?YesNoIf Yes, please explain your routine: Please describe your diet: Daily fluid Intake: Have you had recent exposure to the sun ?YesNoIf Yes, How long On a scale to 1 - 5 how frequently are you in the sun?12345If Yes, when was the last time? do you use tanning beds?YesNOIf Yes, which one and when was the last time? do you use self tanner?YesNOdo you use sun screen daily?YesNOIf Yes, what brand? Which of the fallowing describes your skin?OilyDryNormalAcne proneHave you used any of the following 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 Physical: Have you ever undergone a cosmetic procedure?First ChoiceSecond ChoiceThird ChoiceIf 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 HistoryI 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 complicationsConsent to treatmentsUnderstand 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 GuaranteeI 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 Treatmentplease Initial next to each lineI 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 InformationPayment today will be made with:CashVisa/MasterCardCashiers checkSignature of patient or parent if minor or responsible party Today's Date Scheduling and CancellationsWhile 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
