Blank Form (#1)Patient InformationsEmergency ContactMedical QuestionsPatient HistoryPayment AgreementInformed Medical ConsentPatient InformationsFirst Name Last Name Address City State Zip Code Date of Birth Telephone Occupation Employer Work Phone Email PreviousNextEmergency ContactContact Name Work Phone Address City State Zip Code PreviousNextMedical QuestionsWhat are you being seen for? Consultation Vela Shape Botox Filler Glycolic Peel Chemical Peel Laser OtherWhich conditions would you like to improve? (Please check all that apply) Sun Damage Acne Scarring Stretch Marks Dark Circles Under Eyes Age Spots Enlarged Pores Under Eye Bags Inch Loss Cellulite Reduction Hyperpigmentation Contouring of Neck, Jaw, Cheeks Loss of Collagen & Elastin OtherPreviousNextPatient HistoryDo you bruise easily? Yes NoDo you suffer from a capillary condition? Yes NoDo you suffer from sensitive migraines? Yes NoAre you epileptic or suffer from seizures? Yes NoDo you have any serious illness? Yes NoDo you have low blood pressure or thyroid issues? Yes NoDo you wear contact lenses? Yes NoDo you have any hormone imbalance? Yes NoHow many glasses of water do you drink a day? Yes NoHow many glasses of water do you drink a day? Do you have any allergies? Yes NoDo you take blood thinners? Yes NoDo you suffer from water retention? Yes NoDo you follow an exercise routine? Yes NoAre you pregnant or trying to get pregnant? Yes NoHow sensitive is your skin? Not at all Mild ExtremelyAre you taking any medication? Yes NoHave you had any recent operations? Yes NoDo you have or have you ever had any of the following? (Please check all that apply) Kelloid Scarring Hepatitis Dermatitis Bruising Acne Scarring HIV+ Eczema Melanoma Hemophilia Herpes Simplex Varicose Veins Metal Implants Pace Maker Diabetes OtherDo you use or have you used any of the following products? AHA Hydroquinone Retin-AHave you ever had any of the following treatments? (Please check all that apply) Microdermabrasion VelaShape Botox Filler Glycolic Peel Chemical Peel Laser Cosmetic Surgery Liposuction Tummy Tuck OtherPreviousNextPayment Agreement I hereby guarantee payment of all charges incurred by me today. I answered the following questions truthfully and I understand that some conditions may be indications to receiving treatment. The facility will therefore not accept my liability for injury or damages as a result of false information given. Furthermore, I know that it is my responsibility to alert the therapist about any recent surgeries or skin resurfacing procedures. Without the above disclosure, I understand that the technician cannot optimize the effectiveness of the treatments, which are designed to provide clients with superior results. By Signing below, I consent to the procedure.PreviousNextInformed Medical Consent I authorize Ivan L. Goldsmith, M.D. and his medical staff to perform my elective procedure/procedures including, but not limited to Botox, Dysport, Xeomin, Dermal Fillers, Chemical Peels, and Laser treatments. I have thoroughly researched and understand the nature and purpose of the procedures. I understand the risks and benefits of my desired procedure(s). I further understand that all of these are elective procedures and I may incur side effects including but not limited to bruising, temporary or permanent, drooping or nerve damage, hardening under the skin, scarring, tingling, skin burn or infection. No warranty or guarantee has been made to me on the outcome of the procedure(s) or of a definitive cure. I understand that the explanation I have received is not exhaustive and that more risks and/or complications may arise. I have been offered a safety information handout specific to my procedure(s). If I desire a more complete explanation of any of the foregoing, such explanations will be given to by Ivan L. Goldsmith, M.D. upon my request. I am not pregnant or nursing. If I become pregnant, I will inform Ivan L. Goldsmith, and/or his staff. I understand that not all patients respond equally and results may vary. I hereby consent and authorize Ivan L. Goldsmith, M.D. and/or his staff to perform any of the above mentioned elective procedure(s). Previous Send
