Client Information Form Step 1 of 6 16% Name* Sex* Male Female Date* MM slash DD slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code Cell PhoneHome Phone*OtherDate of Birth* MM slash DD slash YYYY Email Address* Emergency Contact Name* Phone*Relationship* How were you referred?* What are your overall skin and body concerns & goals? Dermatologist in the past year?* Yes No If yes, why?* Last Physical? Weight Height Ethnic background? How is your general health?* Excellent Good Fair Poor Smoke* Yes No How many per day?* Alcohol* Yes No How often?* Per Day?* Please mark the following conditions or treatments that you have/had or experienced Hypertension / Anxiety Cold Sores Anemia Cancer / Cancer Treatments HIV Hepatitis Headaches Fainting Metal Implants Lupus Thyroid Disorders Pace Maker Asthma Claustrophobia Epilepsy / Seizures Diabetes Hernia / Hernia Repair IVF Heart Problems Raynaud’s Disease Cold Uticaria Pregnancy /Breast Feeding Hormone Imbalance Nerve Disorder Sensitive / Sensitized Skin High / Low Blood Pressure Accutane Treatment Auto Immune Disorder – What Kind? Other Untitled* Please list any medication, herbs, nutritional supplements or birth control implants.AllergiesDo you have any known allergies?* Yes No Unknown If yes, please explain* Are you currently having skin treatments?* Yes No If yes, what type of treatment(s)?* Please mark if you have or have you had any of the following in the last 14 days. Facial Cosmetic Surgery Botox Injections Extractions Collagen Injections Permanent Cosmetics Fillers Light Treatments Chemical Exfoliation (Peels) Waxing Laser Hair Removal Laser Resurfacing Microdermabrasion / Leveling Please mark if you are presently experiencing or have experienced in the past. Keloid Scarring Skin Cancer Broken Capillaries Acne Dermatitis or Rash Treatment Reactions Hypo / Hyperpigmentation Skin Care Products Reaction Rosacea / Redness Sensitivities Other Other Home CarePlease circle the skincare products are you currently using at home. Cleanser Serums Toner Exfoliants / Scrubs Moisturizer Specialty Products SPF Mask Benzoyl Peroxide (BP) Glycolic Acid (AHA) Lactic Acid (AHA) Resorcinol Salicylic Acid (BHA) Sulfur Vitamin C Hydrocortisone (HC) Hydroquinone (HQ) Eye Products Topical Antibiotics Tretinoin (Retin A, Retin-A Micro, Renova, Avita) Adepalene (Differin) Azelaic Acid (Azelex , Finacea) Tazarotene (Tazorac ) Isotretinoin (Accutane) Triluma Metrogel Other Other Sun ProtectionDo you use a sunscreen? Yes No If yes, What level of protection? Mineral Based? Yes No Do you sunbathe, tan in a tanning bed or participate in outdoor activities? Yes No Have you had any direct unprotected sun exposure in the last 10 days? Yes No When exposed to the sun do you? Always burn Never burn Sometimes tan Sometimes burn What skin conditions do you want to improve? Acne/Breakouts Rosacea /Redness Facial / Body Scarring Uneven Tone Hyperpigmentation Freckles/ Age Spots Sun damage Enlarged Pores Dehydration Uneven Texture Oiliness Excess Fat Saddle Bags Stretch Marks Loss of facial volume Sagging skin Hypopigmentation Fine Lines/Wrinkles Lip lines Lip volume Veins face / body Dryness Raised Lesions Other Other Body ContouringWhat areas of your body would you like to improve and reduce volume? Have you had surgical or non-surgical body contouring before? Yes No When? What did you have done? Additional InformationDo you have tattoos in areas of treatment concern Is there any other necessary information your skincare specialist should know before beginning your treatment? Yes No If yes, please explain VIDEOTAPE AND PHOTOGRAPHS RELEASE AND AUTHORIZATIONI,* hereby irrevocably consent to and authorize the use and reproduction by Vitenas Cosmetic Surgery/ Mirror Mirror Beauty Boutique and its affiliates, or anyone authorized by any of them, of any and all photographs, electronic images or video footage of me taken by Vitenas Cosmetic Surgery/ Mirror Mirror Beauty Boutique, or that Vitenas Cosmetic Surgery/ Mirror Mirror Beauty Boutique has in its possession, provided either by me or by a third party (collectively, Images) for the purpose of informing the medical profession and the general public about plastic surgery and plastic surgery procedures and techniques without compensation to me. Such use shall include, but not be limited to, distributing the Images via print, visual and electronic media, specifically including the Vitenas Cosmetic Surgery/ Mirror Mirror Beauty Boutique website and social media sites such as YouTube, Facebook and Twitter. The Images (including any photographic negatives) shall be the sole property of Vitenas Cosmetic Surgery/ Mirror Mirror Beauty Boutique. I hereby waive any right to inspect or approve the finished product, photograph, video, DVD, CD-ROM or matter that may be used in conjunction therewith or to the eventual use that it might be applied. I hereby release, discharge and agree to hold harmless Vitenas Cosmetic Surgery/ Mirror Mirror Beauty Boutique and its affiliates and their respective representatives, assigns, and employees, and any person acting under their permission or authority, from and against any claims whatsoever in connection with the use of my Images and the reproduction thereof as stated above, including any claim for payment in connection with distribution or publication of the video and/or photographs. I hereby warrant that I am over twenty-one years of age, and competent to contract in my own name insofar as the above is concerned. I have read and understand the foregoing release, authorization and agreement, before signing my name below, and enter into it knowingly and voluntarily. Date* MM slash DD slash YYYY Printed Name* Signature I have read the above Release and Authorization.I am the parent, guardian, or conservatory of , a minor. I am authorized to sign this authorization on his/her behalf and I give this authorization in the interest of public education. Date MM slash DD slash YYYY Printed Name Signature ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICESI,* have received a copy of this office’s Notice of Privacy Practices.Patient Signature Date* MM slash DD slash YYYY CANCELLATION AND RESCHEDULING POLICY Mirror Mirror Beauty Boutique has a 24-hour cancellation and rescheduling policy for consultations. If you cancel or reschedule your consultation appointment with less than a 24-hour notice or fail to be here for your appointment, $100 will be charged to the credit card on file. Mirror Mirror Beauty Boutique’s cancellation policy exists out of respect for the patients as well as our providers. Cancellations with less than 24-hour notice do not allow other patients the opportunity to schedule an appointment during that time. A 25% non-refundable deposit is required in order to schedule a treatment. We require a notification of at least 48 hours in order to reschedule your treatment appointment at no cost. If your appointment is cancelled within 48 hours or you arrive more than 30 minutes late to a treatment, the 25% deposit will be forfeited. Treatment fees are payable in full on the first scheduled date of service. By signing below, you acknowledge that you have read and understand the cancellation/rescheduling policy for Mirror Mirror Beauty Boutique as described above. I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I also understand that some skin conditions may require more than one treatment and home care products to achieve the result desired. I hereby release Mirror Mirror Beauty Boutique from any liability pertaining to treatments, understanding that results cannot be guaranteed due to individual skin and body type(s) and condition(s). Patient Printed Name* Patient Signature Date* MM slash DD slash YYYY Witness Signature Date MM slash DD slash YYYY Facility Proper Practices Children In order to ensure the safety of children and the enjoyment of all guests, we ask that parents or guardians make other arrangements for children, as we cannot accommodate them during your visit. This allows everyone involved in the appointment to give you the attention you deserve. Pets Only Working Service Dogs Permitted the health and safety of our patients, Mirror Mirror Beauty Boutique has a No-Pets policy. Although we love animals, we ask that you please leave your pet at home during your visit. This No-Pets policy applies to: Pets Emotional Support Animals Comfort Animals Therapy Animals Mirror Mirror complies with the Americans with Disabilities Act (ADA) allowing access for all individuals to public places; therefore, we do allow working service dogs to accompany our patients. Dogs whose sole function is to provide comfort or emotional support do not qualify as service animals under the ADA. The Department of Justice has stated that emotional support animals are not protected as service animals under these regulations. Should you arrive to an appointment with a pet that is not a service animal, you will be asked to reschedule your appointment. To avoid any disruption or inconvenience, we ask that you please leave your pet at home. Thank you for your cooperation and consideration of all our patients.Patient Signature Date* MM slash DD slash YYYY Witness Signature Date MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. Δ
