Name:_______________________________ Date:______________________ Age:___________________ Reason for Today’s Visit: _________________________________________________________
MEDICAL HISTORY Allergies: ____________________________ Last Menstrual Period: ____________________ Medications: __________________________________________________________________ Pregnant or planning a pregnancy? ○ Yes ○ No Nursing? ○Yes ○No Form of Birth Control: _______________ Surgeries: _________________________________ Primary Care Physician: _________________________________
FAMILY HISTORY Has a blood relative ever had any of the following? (Please Circle) Melanoma Other Skin Cancer Cystic Acne Psoriasis Lupus Rosacea Diabetes High blood pressure Cancer Eczema
SOCIAL HISTORY Occupation: __________________________ Employer: __________________________ Do you sunbathe or use tanning beds? ○ Yes ○ No Frequent Sunburns? ○ Yes ○ No Do you wear daily sunscreen? ○ Yes ○ No Do you drink alcohol? ○ Yes ○ No Do you smoke? ○ Yes ○ No
REVIEW OF SYSTEMS Natural/Original Hair Color: ○ Black ○ Brown ○ Light brown ○ Blonde ○ Red Natural Eye Color: ○ Brown ○ Light brown ○ Blue ○ Green ○ Hazel ○ Gray Skin Color: ○ Very pale ○ Fair ○ Medium-olive ○ Dark olive-brown ○ Brown ○ Black
COSMETIC QUESTIONNAIRE
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Patient Demographic Sheet
Name: ______________________________________
Date: _________________
Date of Birth: _________________ Marital Status: S M D W
Address: ___________________________________ City: ________________________
State: ______________________ Zip Code: _________________
Home Phone: ___________________ Cell Phone: __________________
Employer: ________________________________________________________________
Email Address: __________________________________________________________
How did you hear about us? ___________________________________________
Policies and Procedures
Appointments
Please arrive 10 minutes prior to appointment time. Appointment confirmations are made via text
and email. Please provide a valid cell phone number and email address when scheduling
appointments.
Children are not allowed in treatment rooms due to the nature of services provided. Unattended
children are not allowed in the waiting room.
Cancellation Policy
Due to the individualized nature of services we offer, our service providers prepare treatment rooms
and services in advance for each client. If you are unable to keep an appointment, please let us know
at least 24 hours prior to your scheduled appointment. For appointments not cancelled within this
period, you will be charged a $35 fee. If you find that you are running more than 15 minutes late
for an appointment, we ask that you call and reschedule so that we may be on time for other
scheduled clients.
Pricing
The first visit Consultation Fee is $50. This applies to ALL new patients in order to establish with
Greater Mobile Laser & Aesthetic Center.
Pricing for additional services is determined by treatment type, the area to be treated, and the time
required per treatment area. Treatments are sold individually per session or in packages. All services
must be paid in full on the same day of treatment.
Payment Information
Cash, credit cards, checks, and Care Credit are accepted. There will be a $35 fee charged for all
returned checks. All payments are non-refundable.
I have read and understand the policies and procedures of Greater Mobile Laser & Aesthetic Center.
Signature: ________________________________________________ Date: ______________