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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.
Medicinal Benefits of Marijuana Introduction/Background Cannabis preparations have been used as medicinal agents for thousands of years described in a medical context by the Chinese emperor Shen Nung in 2700 BCE to treat beriberi, gout, malaria, rheumatism and numerous other conditions.1 Cannabis was cultivated in Europe and Asia as a fiber plant and ultimately became a central nonc
I was a twentysomething barista (and lived) Bert Vandecasteele – 1.2 – 5th of October, 2010 Before moving to Berlin, I didn't even know what a barista was. I probably didn't even know the difference between espresso and regular coffee. But fate had it planned out for me: for about half a year, I'd go into the lion's den. Yes, I would be a twentysomething barista like so many others. I w