Download 5.1.1 Client General Health Questionnaire

5.1.1 Client General Health Questionnaire
Name:_____________________________________
Date of Birth: ____/____/____
Do you have any major medical problems?
Yes
No
If so, please list:________________________________________________________
_____________________________________________________________________
Do you suffer from “photosensitivity” (extreme sensitivity to sunlight)?
Yes
No
Do you have a history of easy/excessive Hyperpigmentation
Yes
No
Do you suffer from seizures?
Yes
No
Do you form keloid scars?
Yes
No
Have you taken isotretinoin (eg. Accutane) in the past 6 months?
Yes
No
Are you currently taking coumadin (warfarin)?
Yes
No
Have you ever had adverse reactions to laser or cosmetic treatments?
Yes
No
If so, please list:________________________________________________________
_____________________________________________________________________
List all medications to which you are allergic (include allergy to Restylane or Botox): None
_____________________________________________________________________
List all medications, vitamins, herbal medicines, and/or daily supplements you are currently
using and approximately when you started taking the medication: None
MEDICATION
Females:
START DATE
MEDICATION
START DATE
Are you or might you be Pregnant?
Yes
No
Are you Breast feeding?
Yes
No
Are you Trying to become pregnant?
Yes
No
Patient Name: __________________________________
Date:_________________________
Consultant Signature:____________________________
Date:_________________________
Provider Signature:______________________________
Date:_________________________
Private and Confidential
5.1.2 Spa Sydell Client Contact Information
FIRST NAME
LAST NAME
ADDRESS
CITY
STATE
ZIP
CODE
HOME TEL#
CELL#
EMAIL
SEX
MALE
STATUS
WHITE
DATE
OF
BIRTH
SINGLE
FEMALE
ETHNICITY
(OPTIONAL)
MARRIED
HISPANIC
ASIAN
AFRICAN AMERICAN
REFERRED
BY
IN CASE OF
EMERGENCY
PLEASE
CONTACT
NAME
Private and Confidential
TEL#
OTHER
5.3.1 Agreement for Medical Services with Spa Sydell
ARTICLE I: ARBITRATION
Article 1.1: Agreement To Arbitrate: It is understood that any dispute as to medical malpractice by Client,
including any party that would have standing to assert a claim on behalf of or in connection with services provided
to Client, that is as to whether medical services rendered under this contract were unnecessary, unauthorized or
lacking informed consent or were improperly, negligently, or incompetently rendered, will be determined by
submission to arbitration as provided by this agreement and applicable state law, and not by a lawsuit or resort to
court process except as applicable law provides for judicial review of arbitration proceedings. For purposes of this
agreement, “Dispute” means any claim or controversy of whatever kind or nature including (without limitation) any
claim or controversy regarding the formation, validity, interpretation and/or enforceability of this agreement to
arbitrate and any claim or controversy by the Client asserting loss of consortium, wrongful death, emotional distress
or punitive damages. Both parties to this contract, by entering into it, are giving up their constitutional right to have
any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
Article 1.2: Procedure For Initiating Arbitration: Either party to this agreement may initiate Arbitration by
submitting a Demand for Arbitration in writing to the other. The Demand shall contain a plain and simple statement
of the nature of the Dispute and the remedy demanded. There shall be one Arbitrator who shall be a retired Judge of
a court of record. The Arbitrator shall be selected by agreement of the parties on or before 30- calendar days of the
date that the Demand for arbitration is deposited for delivery with a common carrier (as determined by a postmark or
other equivalent writing imprinted by the common carrier). If the parties fail to agree upon an arbitrator, then the
Arbitrator(s) shall be selected in accordance with the rules of the American Arbitration Association.
Article 1.3: Law Governing Arbitration; Arbitrator’s Award And Enforcement. Without reference to its choice
of law rules, the Arbitrator shall apply the substantive law of the state in which the services were rendered. The
Arbitrator shall render his or her award in writing and the award shall separately state the Arbitrator’s findings of
fact and conclusions of law. The Arbitrator’s award shall be binding on the parties to the arbitration and judgment
on the award may be entered by a court of competent jurisdiction. To the extent permitted by law, venue for such
proceedings shall be in the county (or the federal judicial district) where the services were rendered. Unless the
Arbitrator shall determine otherwise, the Arbitration shall take place in the county where the services were rendered.
The Arbitrator shall have the authority to hear any claim and award any remedy that could otherwise be heard or
rendered by a State or federal district court. Discovery shall proceed in accordance with the rules of the American
Arbitration Association. The parties to this agreement agree to arbitrate in one proceeding all claims arising out of
the same or a related incident, transaction or occurrence.
Article 1.4: Severability: If any provision of this arbitration agreement is held invalid or unenforceable, the
remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provisions.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL
MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT
TO JURY OR COURT TRIAL. SEE ARTICLE I OF THE CONTRACT.
I understand that I have the right to receive a copy of his arbitration agreement. By my signature below, I
acknowledge that I have received a copy.
By: __________________________________________
Date: ___________________
Patient / Client Signature (or Patient’s Representative or Guardian)
By: __________________________________________
Date: ___________________
Print Patient’s / Client’s Name
By: ________________________________________________Date: ____________________
Authorized Spa Sydell Representative’s Signature
A signed copy of this document is to be given to the client. Original is to be filed in Client’s medical records.
Private and Confidential
Pre and Post Treatment Instructions Botox® and Dermal Fillers
In order to minimize the risk of possible side effects and complications of injections please
follow these simple steps:
Pre Treatment Instructions
• Do not consume alcoholic beverages at least 24 hours prior to treatment (alcohol may this
the blood and increase the risk of bruising)
• Avoid anti-inflammatory/blood thinning medications for a period of two (2) weeks before
treatment. Medications and supplements such as aspirin, vitamin E, ginkgo biloba,
ginseng, garlic, feverfew, St. John’s Wort, Omega3 Fish Oils supplements, Motrin,
Advil, Aleve, and other NSAIDS have a blood thinning effect and can increase the risk of
bruising and swelling after injections
• Schedule your Dermal Filler and Botox® appointment at least seven to ten days prior to a
special event which you may be attending such as a wedding or vacation. Results from
Dermal Filler or Botox® injections will take approximately four (4) to seven (7) days to
appear. Also, temporary bruising and/or swelling may be apparent in that time period.
• Discontinue Retin-A two (2) days before and two (2) days after treatment.
• Reschedule you appointment at least 24 hours in advance in you have a cold sore,
blemish, or rash on your face.
• If you have a history of cold sores, obtain a prescription from your physician for antiviral
medication. This medication should be used one (1) day prior to and three (3) to four (4)
days after your treatment.
• Be sure to have a good breakfast, including food and drink, before your procedure. This
will decrease the chances of lightheadedness during your treatment.
Post-Treatment Instructions
Post Botox®
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Do not touch or manipulate the area for three (3) hours following treatment. Do not
receive and facial laser treatment or microdermabrasion treatment with Botox®. If these
treatments are desired they should be performed prior to the Botox® treatment.
Smile, Frown, or grimace for 20-30 mins following your treatment. This will help the
Botox® find its way into the muscles into which it was injected.
Do not lie down for four (4) hours after your Botox® treatment. This will prevent the
Botox ® from tracking into the orbit of your eye and causing a droopy eyelid.
It can take approximately four (4) to seven (7) days for results to be seen. If the desired
result is not seen after two (2) weeks of your treatment, contact the clinic. You are
charged for the amount of the product used. Therefore, you will be charged for the
product used during any touch up or subsequent appointments.
Do not perform activities straining, heavy lifting, or vigorous exercise for six (6) hours
after treatment. This will keep the Botox® working in the area it was injected and not
elsewhere.
Private and Confidential
•
Make-up can be applied before leaving the office. Retin-A, Glycolic acid, Vitamin C,
and Vitamin C cream should not be used in the treated areas for 24 hours after treatment.
Post Dermal Filler (Juvederm®/®XC/®Ultra, and or Radisse®)
For 24 Hours after treatment:
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Avoid significant movement or massage of the treated area
Avoid strenuous exercise
Do not apply makeup
Avoid extensive sun or heat exposure
Avoid consuming alcoholic beverages
If you have swelling, you can apply an ice pack for no more than 15mins, once
and hour
Use Tylenol for discomfort
Avoid touching or manipulating the treated area for six (6) hours following
treatment. After six (6) hours, the area can be gently washed. Do not receive a
facial laser treatment or microdermabrasion after treatment with Dermal Fillers. If
these treatments are desired they should be performed prior to the Dermal Fillers
treatment.
Avoid sleeping face down (on your stomach) for two (2) weeks following
treatment
I certify that I have been counseled in the pre and post treatment instructions and have been
given a copy of these written instructions.
Client Signature
Date
Staff Signature
Date
Private and Confidential
Botox® and Dermal Fillers Agreement
Eligibility for Treatment
I understand and acknowledge that the objective of treatment with Botox® and Facial Fillers, as in any
cosmetic procedure, is improvement, not perfection.
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I understand that temporary bruising and swelling commonly accompany Botox® and Facial
Filler treatment.
I understand that my final results will not be apparent for several days to several weeks.
I understand that Injection of Botox® and Facial Fillers is a medical procedure only to be done
by, or under the order of a physician or an advanced practice nurse.
I understand that I will be charged for the amount of Filler/Botox® used. If I desire an additional
treatment or touch up, I will be charged for the additional product used.
I understand that I will be given both pre-treatment and post-treatment instructions. In order to
obtain the best results, I will follow these instructions.
I am not pregnant or nursing
I do not have a history of abnormal scarring, including but not limited to, Keloid formation.
I am not using medications that cause bleeding, including but not limited to, Coumadin, aspirin,
or ibuprofen.
I am not allergic to Botox® and/or the Dermal Filler medications with which I would like to be
treated.
Scheduling Fee
I understand and acknowledge that payment for this procedure includes a scheduling fee of seventy-five
dollars ($75.00) that is due at the date of this agreement. This fee will be applied to the total cost of my
procedure. The remainder of the cost of my procedure will be due prior to checkout on the day of my
appointment. Should it be determined that I am not a viable candidate for this procedure, my scheduling
fee will be returned in full. Due to the high demand and expense of treatment time, I must contact Spa
Sydell at least 24 hours in advance to reschedule or cancel my appointment. Otherwise, a seventy-five
dollar ($75.00) cancellation fee will apply.
I have read and understand the above information. I acknowledge that all answers have been provided
truthfully and will not hold any staff member responsible for any errors or omissions that I have made in
the completion of this form.
Client Signature
Date
Staff Signature
Date
Private and Confidential