Patient Registration Form Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastNICKNAME (if any)Date of BirthMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SexMFMTFFTMDriver's License State & # (if paying by check)Home AddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *PhoneName/Number of Emergency Contact/Guardian (if minor) and Relationship to youHow did you hear about Azura? May we leave messages on your voicemail for appointment reminders? YesNoMay we send text messages to your cell phone for appointment reminders?YesNoIf yes, please select your carrierSelect a CarrierAT&TVerizonSprintT-MobileOtherPayment Information All accounts must be kept current and up to date. Payment is expected at the time of service. Payment can be made in the form of cash, check or credit card. There is a $25.00 fee charged for each returned check. Services bought as a package require 50% down at time of first service and 50% balance at time of second service. All products purchased must be paid for the same day they are purchased. If an appointment is cancelled with less than 24 hour notice or if an appointment is not kept, there will be a $50.00 fee charged to your account after the first occurrence. I have completed the above information and confirm that it is correct. I agree that I have read and understand and agree to the Payment Information section above and consent to be a patient at Azura Skin Care Center, PLLC.SignatureClear SignatureToday's DateHealth InformationI. Medical/Surgical HistoryDo you have now or have you ever had: Any Medical Conditions YesNoIf YES to above, please explain:Prior Surgery?YesNoIf YES to above, please explain:II. Social HistoryDo you currently smoke?YesNoIf yes, how much?Ill. MedicationsList all medications you are taking, including any over-the-counter herbals or vitamins:Medication ListIV. AllergiesAre you sensitive/allergic to any medication?YesNoPlease explainAre you sensitive/allergic to: Papaya/Almond/Pumpkin/Latex/Sulfa or Benzoyl peroxide?YesNoPlease explainV. Dermatological HistoryDo you have now or have you ever had: Keloids/ Abnormal Scarring?YesNoPoor Wound Healing?YesNoAccutane Use (past or present)?YesNoSkin Pigmentation Problems?YesNoReaction to local anesthetics?YesNoCold Sores/Herpes Infections?YesNoEczemaYesNoPsoriasis?YesNoAbnormal/dysplastic moles?YesNoPre-cancerous spots?YesNoSkin Cancer/Melanoma?YesNoSkin Cancer/Basal Cell?YesNoSkin Cancer/Squamous Cell?YesNoAbnormal Cold Sensitivity?YesNoAbnormal Sun Sensitivity?YesNoRosacea?YesNoVery Sensitive Skin?YesNoIf YES to any of the above, please explain:VI. For Females onlyExcess Facial/Body Hair?YesNoIrregular Mentrual Periods?YesNoAre you pregnant?YesNoAre you nursing?YesNoAuthorization to Contact Patient and Record of Disclosures The Health Insurance Portability and Accountability Act {HIPAA) gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.I wish to be contacted in the following manner (check all that apply)EmailLeave a message with call back number onlyOkay to text my cell phoneOkay to mail my home addressOkay to faxOkay to leave a message with detailed InformationWork/Home telephoneWritten communicationOkay to mail to my work/office addressOtherEnter Fax NumberOther (please explain)* Arbitration Agreement (Sheets Provided)SignatureClear SignatureDateRelationship to patient (if minor)*Notice of Privacy Practice (Sheets Provided)SignatureClear SignatureDateRelationship to patient (if minor)Acknowledgement That you have read NOTICE OF PRIVACY PRACTICES and PROVIDER PATIENT ARBITRATION AGREEMENT *I have read NOTICE OF PRIVACY PRACTICES and PROVIDER PATIENT ARBITRATION AGREEMENTView Notice of Privacy Practices View Provider-Patient Arbitration AgreementSubmit