New Patient Form Patient InformationFirst Name Last Name Phone/Mobile Text Input Text Input Phone/Mobile Email Emergency ContactText Input Phone/Mobile Medical QuestionsWhat are you being seen for? Consultation VelaShape Botox Filler Glycolic Peel Chemical Peel Laser OtherText Input Which 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 OtherText Input Patient HistoryDo you bruise easily? Yes NoDo you wear contact lenses? Yes NoDo you suffer from water retention? Yes NoDo you suffer from a capillary condition? Yes NoDo you have any hormone imbalance? Yes NoDo you follow an exercise routine? Yes NoDo you suffer from sensitive migraines? Yes NoDo you smoke? Yes NoAre you pregnant or trying to get pregnant? Yes NoAre you epileptic or suffer from seizures? Yes NoHow many glasses of water do you drink a day? How sensitive is your skin? Not at all Mild ExtremelyDo you have any serious illness? Yes NoText Input Do you have any allergies? Yes NoText Input Are you taking any medication? Not at all Mild ExtremelyText Input Do you have low blood pressure or thyroid issues? Yes NoText Input Do you take blood thinners? Yes NoText Input Have you had any recent operations? Not at all Mild ExtremelyText Input Do 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 DiabetesTextarea Have 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 OtherText Input Do you use or have you used any of the following products? AHA Hydroquinone Retin-APayment AgreementCheckbox Field I hereby guarantee payment of all charges incurred by me today. Checkbox Field 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.Informed Medical ConsentCheckbox Field 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.Checkbox Field No warranty or guarantee has been made to me on the outcome of the procedure(s) or of a definitive cure. Checkbox Field 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.Checkbox Field I am not pregnant or nursing. If I become pregnant, I will inform Ivan L. Goldsmith, and/or his staff.Checkbox Field I understand that not all patients respond equally and results may vary. Checkbox Field I hereby consent and authorize Ivan L. Goldsmith, M.D. and/or his staff to perform any of the above mentioned elective procedure(s).Send