REGISTRATION FORM with Med History

Full Name

First Name Last Name
Date of Birth

Month Day Year
Phone *

Area Code Phone Number
E-mail *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Emergency contact information *

First Name Last Name
Phone Number *

Area Code Phone Number
Scheduling & Confirmations *

By entering in my mobile number above, I authorize Timeless Beauty Aesthetics LLC to send me text messages regarding my appointments, my account and about products, services promotions using an automatic messaging system. I understand that I am not required to check this box as a condition of purchasing any property, good, or service. (If I receive a text message, I can reply HELP for support and/or reply STOP to OPT out of consent. Message and data rates may apply.
Marketing Communication

I authorize Timeless Beauty Aesthetics LLC to send email, mobile, sms, mms, and print communications to send educational, marketing and promotional commuication. I understand that I am not required to check this box as a condition of purchasing any property, good, or service. (If I receive a text message, I can reply HELP for support and/or reply STOP to OPT out of consent. Message and data rates may apply.
What brings you in today? What other areas are you concern with?
DESCRIBE YOUR CONCERNS (OPTIONAL)
Referred by?
Patient Medical Information
Are you currently taking prescription medications?

Yes No
List Medications (If answer yes above)
Are you allergic to any medications?

Yes No
List Medications/allergens
Are you currently pregnant?

Yes No Possibly
Do you have or had any of the following?

Asthma Bronchitis Shortness of breath Emphysema Headaches Numbness or tingling Chest pain Vision or Hearing Infection desease Neck injury Diabetes Join replacement surgery Cancer Angina Dizziness of Fainting Peacemaker Weakness High blood pressure Stroke Hernia Heart attack or heart surgery Weight loss Energy loss Bowel or bladder problems Varicose veins Epilepsy/Seizures Blood clot/ Embolia Allergies Thyroid Congestive heart disease Metal implants Anemia Chemotherapy/ Radiation Arthritis Osteoporosis Back Injury or surgery Gout Smoking Emotional/ Psycochological Problems STD's Pelvic pain Sleeping problems Bladder/Kidney Infection
COVID-19 Risk Informed Consent *

I understand that I am opting for an elective treatment/procedure/surgery that is not urgent and may not be medically necessary. I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that Michelle Hoff and all the staff at Timeless Beauty Aesthetics are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment/procedure/surgery. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure/surgery, and I give my express permission for Michelle Hoff and all the staff at Timeless Beauty Aesthetics to proceed with the same. I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective treatment/procedure/surgery can lead to a higher chance of complication and death. I understand that possible exposure to COVID-19 before/during/after my treatment/procedure/surgery may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death. In addition, after my elective treatment/procedure/surgery, I may need additional care that may require me to go to an emergency room or a hospital. I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the treatment/procedure/surgery itself. I have been given the option to defer my treatment/procedure/surgery to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment/procedure/surgery.
I have read and agree with the cancellation policy. *

Yes
Patient Signature *

SIGNATURE Clear
Date

Month Day Year
Should be Empty:

Patient Medical Information