3655 Howell Ferry Road

3655 Howell Ferry Road

Suite 400

Duluth, GA 30096

678-417-6900

ColeDermCosmetic.com

PATIENT REGRISTRATION FORM

Name:______

Address:______

City State Zip Code

Date of Birth______Sex M/F______Social Security #______

Home #______Cell #______Email:______

Emergency Contact______Phone______Relationship______

Employer-Name______Phone______

Primary Care Physician-Name______Phone______

Pharmacy-Name______Phone______

PRIMARY INSURANCE______

Policy #______Group #______Policy-Holder______

Do we have your permission to? (please circle yes or no)

Leave a Message on your answering machine at home? Yes No OR cell phone? Yes No.

Leave a message at your place of employment? Yes No

Discuss your medical condition over the phone with YOU? Yes No

Discuss medical condition with any member of your household? Yes No

If yes, with whom:______Relationship______

FINANCIAL STATEMENT:

To establish optimal relations with our patients and avoid misunderstandings regarding our payment policies, our staff is trained to inform you of the financial policies of this office. PAYMENT IS EXPECTED FROM YOU, AT THE TIME OF SERVICE, FOR "YOUR PART" OF THE CHARGES. FOR YOUR CONVENIENCE WE ACCEPT CASH, CHECKS, VISA, MASTERCARD and AMERICAN EXPRESS. Your signature below indicates that you understand and accept this policy. Further, your signature authorizes the doctor to release such medical information necessary to process your insurance claims (if any). You herein authorize payment of medical benefits to the doctor when assigned claim is filed.

NO-SHOW/CANCELATION POLICY:

I understand that a charge in the amount of $50.00 will be charged to my account if I do not notify the office within 24 hours of appointment to cancel or reschedule my appointment.Arrival of more than 15 minutes late to an appointment constitutes as failure to cancel within the 24 hour window.

I understand that a cosmetic fee of $75.00 will be charged for any cosmetic consultation and will be deducted from cosmetic procedure at time of payment. All cosmetic procedures are to be paid at time of scheduling. No-show of a cosmetic procedure will result in a loss of 50% of pre-paid amount.

My signature below signifies my understanding and willingness to comply with these policies.

______

Signature of Patient, Parent or Legal Guardian Date

3655 Howell Ferry Road

Suite 400

Duluth, GA 30096

678-417-6900

ColeDermCosmetic.com

MEDICAL HISTORY INFORMATION

Patient Name______Date of Birth______

Reason for today’s visit: ______

Past/Current Medical history (please list all conditions below):

Past Surgical History:

Current Medications (including all supplements):

Allergies:______Do you have a family history of Melanoma?______

______

______If yes, which relative?______

Skin Disease History (please circle all that apply):

AcneEczemaDysplastic NeviRosaceaPsoriasis

Blistering sunburnsBasal Cell Skin CancerSquamous Cell Skin CancerMelanomaDry Skin

Poison IvyAllergiesOther: ______

At Cole Dermatology & Aesthetic Center we offer a variety of cosmetic procedures. Please circle any procedures you are interested in learning more about:

Acne Laser TreatmentsSculpSure Laser for Fat Reduction

Acne Scarring TreatmentsSkin Resurfacing

Anti-Aging Medical Grade ProductsSkin Tightening

BotoxTattoo Removal

Chemical PeelsVaginal Rejuvenation

Fillers

FotoFacial for discoloration & redness

Fraxel for skin rejuvenation

Hand Rejuvenation

Laser Hair Reduction

Laser Treatment for Age Spots______

Lip InjectionPatient SignatureDate

3655 Howell Ferry Road

Suite 400

Duluth, GA 30096

678-417-6900

ColeDermCosmetic.com

PATIENT CONSENT FORM

Our Notice of Privacy Practices provides information about how we may disclose Protected Health Information about you. The Notice contains a Patient’s Rights section describing your rights under the law. You have the right to review our Notice before signing the consent. The terms of our notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how Protected Health Information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, except in certain limited instances, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of Protected Health Information about you for non-subsidized treatment, payment and health care operations, and for other purposes as permitted or required by law. You have the right to revoke the consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

The patient understands that:

• Protected Health Information may be disclosed or used for treatment, payment or health care operations, or for other purposes permitted or required by law. However, we will obtain from you a separate written authorization for “subsidized” disclosures, meaning disclosures involving product or service with respect to which the practice receives remuneration from a third party.

• The practice has a Notice of Privacy Practices and that the patient has the opportunity to review the Notice.

• The practice reserves the right to change the Notice of Privacy Policies.

• The patient has the right to restrict the uses of their information but the practice does not have to agree to those restrictions, except in certain limited instances.

• The patient may revoke this consent in writing at any time and all future disclosures will then cease.

• The practice may condition treatment upon the execution of this consent.

This consent was signed by:______

Printed Name – Patient or Representative

Relationship to patient (if other than patient):______Date:______

In front of:______Date:______

Printed name – Patient or Representative