HIPAA Consent Form I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I have been informed by you of your Notice of Privacy Practice containing a more complete description of the users and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a copy of the current Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. I give permission to the staff at Legacy Health & Wellness to discuss my account information with the following people: A copy of the Notice of Privacy Practices will be provided to you at your request Patient name: Date: Signature: Relationship to Patient: Please indicate below the methods that this office may use to contact you: You may contact me at my home telephone number Yes No You may leave a message on my home answering machine Yes No You may contact me on my cell phone Yes No You may leave a message on my cell phone voicemail Yes No You may contact me at my work telephone number Yes No You may leave a message on my work voicemail Yes No You may leave a message with another person at the home telephone number Yes No You may leave a message with a co-worker Yes No You may contact my emergency telephone number
and leave a message Yes No
Patient Information Name (First) (MI) (Last) DOB / / Address City State Zip Code Home Phone Cell Phone Is it OK if we send you messages via text? Yes No Email Address Would you like to be added to our newsletter database? (may opt out anytime) Yes Sex Male Female No Marital Status Single Married Divorced Widowed Occupation Employer Work Phone Preferred Pharmacy Phone Spouse Information Name DOB / / Occupation Employer Work Phone How did you find out about us? Referral from Physician Friend or Family Member Radio TV Internet Other Physician that Referred You: Name Specialty Phone Address City State Zip Primary Care Physician (if other than referring physician): Name Specialty Phone Address City State Zip In Case of Emergency, Contact Phone Relation to: _ I hereby consent to evaluation, testing, and treatment/procedures that are provided to me or the patient for whom I am responsible. This would include all providers, nurses, and interns that are affiliated with Legacy Health & Wellness. Patient Signature: Date:
MEDICAL HISTORY FORM Last Name: First Name: MI: Allergies: o none o yes, please list: Height: Weight: (food, medications, latex, or other substances) What are you here for today? o Vein screening o IV therapy o Laser consultation o Procedure: (please list) Which body area/areas or condition would you like treated? o Face o Nose o Under Lip o Chin o Rosacea o Neck o Chest o Forearms o Under Arms o Full arms o Hands o Back o Bikini o Lower Legs o Full Legs o Scars o Stretch Marks o Other: Please answer all of the following questions 1. Do you have ANY current or chronic medical illnesses? (Please circle below) Diabetes yes no High blood pressure yes no Heart attack yes no Heart disease yes no Heart failure yes no Atrial Fib yes no High Cholesterol yes no Stroke/mini stroke yes no Seizures yes no Gastric Ulcers yes no COPD/Asthma yes no Emphysema yes no Hepatitis yes no HIV yes no Arthritis yes no Lupus yes no Gastric Reflux yes no Kidney Disease yes no Depression yes no Fibromyalgia yes no 2. Do you have ANY current or chronic skin conditions? (Please circle below) History of vitiligo yes no Eczema yes no Melasma yes no Psoriasis yes no Allergic Dermatitis yes no Ehlers-Danlos Syndrome yes no Scleroderma yes no Skin Cancer yes no Blood Clots yes no Thyroid Disease yes no Bleeding Disorder yes no Anesthesia problems yes no Pacemaker yes no Immunosuppression yes no Photosensitive Disorders yes no Heat Urticaria yes no Cancer yes no Other: Other skin condition(s): 3. Do you smoke? o yes o no If yes, when did you quit? 4. Have you underwent any surgical procedures: o yes o no If yes, please list what surgery and when: 5. Are you currently under a doctor s care? o yes o no If so, for what reason: 6. Do you take/use ANY medications (prescriptions and non-prescriptions), vitamins, herbal or natural supplements, on a regular or daily basis? o yes o no If yes, please list below or provide a list: 7. Are there any topical products (both medical and non-medical) that you use on your skin on a regular or daily basis? o yes o no If yes, please list below or provide a list: 8. Does your family have any history of the following: o Heart Disease o Hypertension o Kidney Disease o Varicose Veins o Blood Clots o Bleeding Disorder o Aneurysm o High Cholesterol o Cancer o Stroke/Mini stroke o Diabetes o Other: MEDICAL HISTORY FORM Page 1 of 2
MEDICAL HISTORY, CONTINUED VEIN Consultations ONLY YES NO 1. Do you or have you ever worn compression hose? o o 2. Do you experience any pain your legs? o o If so, please describe: o aching o throbbing o cramping o heaviness o sharp o shooting o restless 3. Do you have any leg swelling? o o 4. Do you have any skin discoloration? o o 5. Do you have any current of history of any problems with ulcers? o o 6. Do you have any of the known following conditions: (Please check below) o Varicose Veins o Spider Veins o Phlebitis o Cellulitis o Chronic venous insufficiency 7. Have you had any procedures performed on your veins? (Please check below) o o o Sclerotherapy o Phlebectomy o Vein stripping o RF Ablation o EVLT Laser LASER Consultations ONLY YES NO 1. Do you take/use ANY systemic/oral steroids (e.g., prednisone, dexamethasone)? o o 2. Do you have ANY allergies to medications, foods, latex or other substances? o o Please List: 3. (For women) are you or could you be pregnant? o o 4. (For women) are menstrual periods regular, or have you o o ever been diagnosed with Polycystic Ovarian Disorder? 5. Do you have a history of herpes I or II in the area to be treated? o o 6. Do you have a history of keloid scarring or hypertrophic scar formation? o o 7. Do you have a history of light induced seizures? o o 8. Do you have any open sores or lesions? o o 9. Do you have any history of radiation therapy in the area to be treated? o o 10. In the last six (6) months, have you used any of the following: o o anticoagulants or blood-thinning medications; photosensitizing medications; or antiinflammatory or blood thinning medications? Please List product name and date last used: 11. In the last three (3) months, have you used any of the following products: glycolic acid or other alpha hydroxy or beta hydroxy acid products; exfoliating or resurfacing products or treatments? o o Please List product name and date last used: 12. Do you have or have you ever had any permanent make-up, tattoos, implants, or fillers, including, but not limited to, collagen, autologous fat, Restylane, etc.? o o If yes, please list locations on or in the body and dates: _ 13. Do you have or have you ever had any Botulinums, such as Botox or Dysport? o o If yes, please list locations on or in the body and dates: 14. Have you taken Accutane (or products containing isotretinoin) in the last 12 months? o o 15. Have you taken Tretinoin (like Retin-A, Renova ) in the last 6 months? o o 16. Have you had any unprotected sun exposure, used tanning creams (including sunless tanning lotions) or tanning beds or lamps in the last 4-6 weeks? o o Patient Signature: Date: MEDICAL HISTORY FORM Page 2 of 2