Skin Essentials Laser and Therapeutic Skin Care Center - Richmond Hill Savannah GA Hilton Head Bluffton SC

10634 Ford Avenue
Richmond Hill, GA 31324
Phone: 912.756.3942

Home

Services

Fields marked with * are required. When you have completed filling out the form, click the SUBMIT button to proceed.

*Name:

First:

*Last:

M.I

Name you prefer to be called:

*Address:

*City:

*State:

*Zip:

*Home Phone:

format ##########

Cell Phone:

format ##########

*Email address:

*Date of birth:

/ / mm/dd/yyyy Age:

*Gender:

Marital Status:

Employment Information

Employer:

Occupation:

Employer Address:

City:

State:

Zip:

Work Phone:

format ##########

Social Security #:

Driver's License #:

In Case of Emergency

Name:

Phone: Relationship:

Spouse:

Phone: format ##########

Family Physician:

Phone: format ##########

*How did you hear about us?

Medical History

Are you in good health at present?

Yes

Are you currently under a doctor's care?

Yes

If yes, what for?

*List any medications you are taking:
(if none, enter n/a)

Name of Medication:	Dosage:

*List any medications you are allergic to:

(if none, enter n/a)

Check any that you have a history of:

	High blood pressure		Glaucoma
	Diabetes		Heart attack
	Headache		Swelling feet
	Serious injuries

Describe improvements you would like to see in health:

Past medical history:
(Check all that apply)

polio	lung disease	kidney problems
arthritis	drug abuse	cancer
scarlet fever	liver disease	osteoperosis
ulcers	gout	rheumatic fever
thyroid disease	eating disorder	anemia
heart valve disorder	heart disease	psychiatric illness
alcohol abuse	blood transfusion	Other (specify below)

Family history:

	Age	Health	Disease	Cause of Death (if any)	Overweight?
Father
Mother
Brothers
Sisters

Has any blood relative had any of the following:

Glaucoma		Who?
Asthma		Who?
Epilepsy		Who?
High Blood Pressure		Who?
Kidney Disease		Who?
Diabetes		Who?
Psychiatric Disorder		Who?
Heart Disease/Stroke		Who?

Skin Evaluation

Skin History:

	Fever blisters		Psoriasis
	Eczema		Rosacea
	Acne		Skin cancer

Skin Conditions:

	Acne		Acne scarring
	Sun damage		Pigmentation
	Texture		Uneven tones
	Enlarged pores		Wrinkles

Check any that you are currently taking or using:

	Antibiotics		Hormones
	Accutane		Retin A, Renova
	Aspirin		Vitamin A, Afirm
	Blood thinner		Exfoliating cleanser
	Steroid creams		Glycolic acid

Have you had prior:

	Chemical peels		Botox
	Facial surgery		Collagen injections

Do you wear contacts?

Yes

Do you wear any medicated patches?

Yes

Could you be pregnant?

Yes

Do you wear any electronic devices?

Yes

Are you claustrophobic?

Yes

Are you receiving chemotherapy treatments?

Yes

Do you have any metal plates or shunts?

Yes

Are you receiving radiation treatments?

Yes

Have you ever had trouble with clotting?

Yes

When was your last skin exam?

Results?

Financial Policy

Thank you for selecting Skin Essentials for your health care needs. We are honored to be of service to you. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all services and products will be due at the time services are rendered, unless prior arrangements have been made. For your convenience, we accept Visa, MasterCard, and cash.

Skin Essentials is not responsible for reactions caused by the guest and for reactions caused as a result of the information above not being correct or complete. I understand that this information will be used only by the providers of Skin Essentials and will be held in confidence; information will not be released to anyone without my written consent.

* I Agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney’s fees and court costs.

* I have read and understand all of the above and have agreed to these terms.

*Enter full name (e-signature):

Hours

Tuesday 8 - 4

Wednesday
8 - 5:30

Thursday 8 - 7

2nd & 3rd
Saturday of each month
8 - 12