Skin Secrets MedSpa LLC Step 1 of 4 25% Patient InformationOffice use only. Select All Upside Constant Contact Aspire Name* Date* MM slash DD slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code Age* Date of Birth* MM slash DD slash YYYY Home PhoneMay we leave a message? Yes No Work PhoneMay we leave a message? Yes No Mobile PhoneMay we leave a message? Yes No Email* May we text you for specials?* Yes No May we text you for appointment confirmations?* Yes No Occupation* How did you hear about us?* Emergency Contact Name* Relationship* Emergency Contact Phone Number*Primary Physician* Phone*Pharmacy Name* Phone*Are you interested in discussing our financing options?* Yes No Contact me via e-mail with promotional offers?* Yes No Skin Secrets does not bill insurance for standard services. Please be advised that payment is due at the time of service. A $40 charge will be assessed on a returned or stopped payment check and/or a credit card reversal. Thank you for your understanding and your patronage. We appreciate your business!Signature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Patient Medical HistoryAre you under a physician’s care?* Yes No If yes, please specify condition:*Please list any medications, including prescriptions and over-the-counter medicines you are currently taking.MedicationReason for taking: Click the plus (+) icon on your right hand side to add new rows.Please list any current medical conditions, previous hospitalizations, and/or surgeries.Date Click the plus (+) icon on your right hand side to add new rows.Are you pregnant?* Yes No Are you HIV positive?* Yes No Do you use tobacco products?* Yes No Quit Using How Long Ago?* Are you prone to cold sores?* Yes No Do you have any neurological or rheumatologic conditions?* Yes No Are you allergic to any of the following?* Select All Alpha-Hydroxy Acid Sulfa Drugs Aspirin Epinephrine Latex Sunscreen Tetracaine Hydroquinone No Allergies Others If "Others", please list.* Click the plus (+) icon on your right hand side to add new rows.Agreement* I agree to the following statements below.I agree that I am not receiving a skin cancer screening at Skin Secrets. I agree to receive a skin cancer screening of all moles and age spots at least yearly by a dermatologist of my choosing. Signature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY PoliciesCancellation Policy Skin Secrets has a 24-hour cancellation policy. $50 fee will be charged to the credit card on file for any missed appointments not cancelled or re-schedule at least 24 hour in advance. Missing or cancelling multiple appointments may be subject to more penalty fees. Return Policy Packages and pre-paid treatments are good for 1 year after date of purchase. If for some reason, you are not satisfied with an un-rendered, pre-paid service, the remaining balance can be used towards other services at Skin Secrets. Because of the nature of our medical grade and prescription skin care products we cannot return products that have been opened. All services are non-refundable.Payment plans All payments are due at the time of service. We always accept cash, check, Visa, Master Card, Discover, and American Express. Acknowledgement By my signature below, I certify that I have read and fully understand the contents of this financial policy.* I attest that all information including but not limited to my personal identification and medical history is complete and true to the best of my ability.** I understand that my consult with the staff of Skin Secrets Medspa and Dr. McLaren is a courtesy and complimentary. In exchange for their time, I attest that I am here solely for the purpose of getting information for my own personal use and not for other purposes such as information to be gained for other medical spa, Plastic surgery or Dermatologic clinics.** I attest that I do not work for a Plastic Surgeon, Dermatologist or Medical Spa.** I agree not to use any type of recording advice during any of my visits at Skin Secrets without the express permission of Dr. McLaren.*Signature* Reset signature Signature locked. Reset to sign again Name* Date MM slash DD slash YYYY Acknowledgement of Receipts of Notice of Privacy Practices**You May Refuse to Sign This Acknowledgement** I have received a copy of this office’s Notice of Privacy Practices.Name Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. We'd love to hear from you! To know our current specials text the word: SECRETS to 797979 for a FREE $25 Gift Card See Our Latest Specials!
