Abqlaser.com

Patient Registration
Name__________________________________ Birthdate __________________ Age ______ Sex M / F Social Security # ________________________ Address______________________________________________________________________________ Patient’s Employer __________________________________________ Occupation ______________________ Employer Address ____________________________________________Telephone #______________________ Primary Doctor _______________________________Primary Dr. Telephone # _________________________
Preferred Pharmacy____________________________ Pharmacy Telephone #__________________________
How to contact you: We take your privacy very seriously.
If we need to contact you regarding your care, please identify the best way to reach you.
Leave general message with call back number only.
Cell Phone ___________________________ Leave general message with call back number only.
Leave general message with call back number only.
OK to fax to this number __________________________________ OK to e-mail to this web address ____________________________ If we are unable to speak directly with you, please list spouse, family members or friends with whom we can
speak regarding your appointments, surgical dates, or other personal health information.
Name___________________________ Telephone #_________________ Relationship____________ Name___________________________ Telephone #_________________ Relationship____________ Whom should we contact in the event of an emergency?
Name___________________________ Telephone #_________________ Relationship____________ Current Medical Conditions
Have you ever been treated for any of the following conditions? (Circle all that apply)
Please list any other conditions for which you are or have been under a physician’s care:______________________________________________________________________________________________________________________________________________________ Current Medications:
Are you taking any of the following medications? (Circle all that apply.)
Please list any other medications you are presently taking:________________________________________________________________________________________________________________________________________________________Please list any known allergies to medication, foods, etc:________________________________________________________________________________________________________________________________________________________ FEMALES ONLY: Are you pregnant, possibly pregnant or considering pregnancyin the near future? ______Yes ______No Skin Protocol:
Please circle the category that best describes your skin color and tendency to sunburn:
I. Very white or freckled always sunburn.
II. White usually sunburnIII. White to Olive sometimes sunburnIV. Brown rarely sunburnV. Dark Brown very rarely sunburnVI. Black never sunburn Please circle the category that best describes your skin type:
I. Problematic (Acne, Psoriasis, Rosacea, Eczema)II. OilyIII. T-zone or Combination SkinIV. NormalV. DryVI. Sensitive (Allergic reactions to some skin care products) Patient Name_____________________________________________ DOB_____________ Previous Cosmetic Facial Treatments:
Areas of Concern Regarding Your Skin:
What skin care products do you use regularly:
Product Name
Facial Cleanser _______________________________________________________________
Facial Toner _________________________________________________________________
Facial Moisturizer ____________________________________________________________
Sunscreen / Sunblock __________________________________________________________
Make-up ____________________________________________________________________
How did you hear about us? ____Mail ____ Newspaper Ad _____Website _____ Radio Ad
Physician/Dentist____________________________________________ Salon _____________________________________________________ Friend_____________________________________________________ Would you like to receive our special e-mail offers? _____Yes _____ No I have answered these questions truthfully and will notify ALC of any changes in medications or my physical conditions. I have received or viewed on-line a copy of the ALC Privacy Policy. If I have given permission to leave detailed messages, fax or e-mail information regarding my care, and/or discuss my medical care with specific family and/or friends, I understand that I am granting a waiver of my privacy rights under HIPAA. If I decide to change these instructions, I will notify ALC in writing as soon as possible. If I have given my email address above, I understand that email is not privacy protected.
Patient Signature________________________________________ Date ___________________ Patient Name___________________________________________ DOB_________________ Registration for a Minor**
**A minor is a young person under the age of 18 years.
Patient Name____________________________________________________________ Birthdate __________________ It is legally necessary for this office to have written consent from an adult for the medical treatment of a
minor. Consent for treatment can only be given by a natural or adoptive parent, an adult with legal custody
of the minor, or a legally appointed guardian. For this reason, please identify your relationship to the minor
patient and the legal basis for your authorization of treatment. Please check the status that applies:
I am the ________ biological / adoptive parent __________ legal custodian __________ court-appointed guardian of the minor seeking medical treatment.
The information indicated on this form is true and accurate to the best of my knowledge. NOTE to Legal Custodians and Legal Guardians: You may be asked to provide proof of your status.
Please bring a copy of your legal documents to the office at the time of the child’s visit.

Source: http://abqlaser.com/wp-content/uploads/2012/05/Patient_Info_Form.pdf