New Patient Form

Patient Information

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First Name

Last Name

Phone/Mobile

Text Input

Text Input

Phone/Mobile

Email

Emergency Contact

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Text Input

Phone/Mobile

Medical Questions

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What are you being seen for?

Consultation

VelaShape

Botox

Filler

Glycolic Peel

Chemical Peel

Laser

Other

Text 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

Other

Text Input

Patient History

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Do you bruise easily?

Yes

No

Do you wear contact lenses?

Yes

No

Do you suffer from water retention?

Yes

No

Do you suffer from a capillary condition?

Yes

No

Do you have any hormone imbalance?

Yes

No

Do you follow an exercise routine?

Yes

No

Do you suffer from sensitive migraines?

Yes

No

Do you smoke?

Yes

No

Are you pregnant or trying to get pregnant?

Yes

No

Are you epileptic or suffer from seizures?

Yes

No

How many glasses of water do you drink a day?

How sensitive is your skin?

Not at all

Mild

Extremely

Do you have any serious illness?

Yes

No

Text Input

Do you have any allergies?

Yes

No

Text Input

Are you taking any medication?

Not at all

Mild

Extremely

Text Input

Do you have low blood pressure or thyroid issues?

Yes

No

Text Input

Do you take blood thinners?

Yes

No

Text Input

Have you had any recent operations?

Not at all

Mild

Extremely

Text 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

Diabetes

Textarea

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

Other

Text Input

Do you use or have you used any of the following products?

AHA

Hydroquinone

Retin-A

Payment Agreement

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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 Consent

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Checkbox 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.

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No warranty or guarantee has been made to me on the outcome of the procedure(s) or of a definitive cure.

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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.

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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).

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