Patient Registration Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastNickname (if any)Date of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex *MFMTFFTMDriver's License State & # (if paying by check)Home Address *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Phone *Name/Number of Emergency Contact/Guardian (if minor) and Relationship to you *How 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&TBoostCricketMetroT-MobileUS CellularVerizonOtherPayment 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.Signature * Clear Signature Today's Date *Health 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? *YesNoEczema? *YesNoPsoriasis? *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 Menstrual Periods?YesNoAre you pregnant?YesNoAre you nursing?YesNoSkin Typing MatrixPlease answer the below questions by selecting an option from the dropdown menu. Your clinician will total your score during the consultation. My ethnic origin is closest to: *Very Fair (Celtic and Scandinavian)Fair-Skinned Caucasians With Light Hair and Light EyesPale-Skinned Caucasians With Dark Hair and Dark EyesOlive-Skinned (Mediterranean, Some Asian, Some Hispanic)Dark-Skinned (Middle Eastern, Hispanic, Asians,)Very Dark-Skinned (African)My eye color is: *0 - Light Blue1 - Blue/Green2 - Green/Gray/Golden3 - Hazel/Light Brown4 - BrownMy natural hair color at age 18 was: *0 - Red1 - Blonde2 - Light Brown3 - Dark Brown4 - BlackThe color of my skin that is not normally exposed to sun is: *0 - Pink to Reddish1 - Very Pale2 - Pale With a Beige Tan3 - Light Brown4 - Medium to Dark Brown5 - Dark Brown to BlackIf I go out into the sun for an hour or so without sunscreen and have not been out in the sun for weeks, my skin will: *0 - Burn, Blister and Peel1 - Burn, Then When Burn Resolves There Is Little or No Color Change2 - Burn, but Then Turns to Tan in a Few Days3 - Get Pink, but Then Turns to Tan Quickly4 - Just Tan5 - Just Gets Darker6 - My Skin Color Is So Dark I Can’t TellWhen was the last time the area to be treated was exposed to natural sunlight, tanning booths or artificial tanning cream? *0 - Longer Than One Month Ago1 - Within the Past Month2 - Within the Past Two Weeks3 - Within the Past WeekYour Clinician Will Total Your Score During the ConsultationIf you sustain an injury to your skin such as a cut, burn, or bruise, how Long does it take to fully resolve without any hyperpigmentation? *What happens if you get an insect bite? *Authorization to Contact Patient and Record of Disclosures (copy)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 AgreementView Arbitration Agreement (Opens in New Tab)Signature * Clear Signature Date *Relationship to patient (if minor)*Notice of Privacy PracticeView Privacy Practice (Opens in New Tab)Signature * Clear Signature Date *Relationship to patient (if minor)*Notice of Cancellation, No-Show, and Deposit PoliciesView Cancellation and No-Show Policy (Opens in New Tab)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 the time of the first service and a 50% balance at the time of the second service. All products purchased must be paid for the same day they are purchased. If an appointment is canceled with less than 24-hour notice or if an appointment is not kept, there will be a $50.00 fee charged to your account.ALL deposits for services are NON-REFUNDABLE.Signature * Clear Signature Date *Relationship to patient (if minor) (copy)Submit