in orderfor us to achieve our goal o.fproviding you with ...€¦ · trinity aesthetic centre. in...
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TRINITY AESTHETIC CENTREIn orderfor us to achieve our goal ofproviding you with optimal care Laser Non-Surgical amp Cosmetic Dermatology
pleasefill out both pages prior to your appointment wwwtrinitydermflcom
ABOUTYOU
Todays Date______________
NAME
Address___________________
CITY STATE ZIP
Date of Birth
Home _________ Ok to leave message__ yes __ no
Cell _________________
Work __________________
EMAIL _ ______________
SpouseNamc____ _ _ _________________
Emergency Contact ____________________
Name amp Relationship ________________
What is Your Occupation_______________
Primary Physician Name _______________
Primary Physic ian Address _________________
CITY STATE ZIP
Primary Physician Phone _______________ _
INSURANCE Primary Insurance Company______________
Insurance Policy __________________
Group ______ Type PPOIl-UvIO___ Other
Co-Pay $______ Refen-al Required Yes__ No__
Insured Name
Insured 5S _______ Insured Birth Date ______
Insured Employer __ _________________ ______________________________________________
Secondary Insurance Company_____________
Insurance Policy _ _ _____________
Group ______ Type PPOIHNIO___ Other
Co-Pay $______ Referral Required Yes__ No__
Insured Name _______ _ ____ _ ___ _
Insured SS ________ _ Insured Birth Date _____
Insllfed EmpJoyer_____________ ____________ _________________ ____ __________ ___ __________ __ __ __ _____________ _
PLEASE CHECK IF YOU ARE INTERESTED IN
__ BOTOX (Can soften the appearance of the wrinkles
around your eyes forehead and frown lines)
__ RESTYLANE JUVEDERM (Fillers that can improve
the appearance of the larger wrinkles around your face
such as the laugh lines)
__ LASER HAIR REMOVAL (permanently decrease hair
production)
__ CHEMICAL PEEL (a procedure to improve the
appearance of your skin resulting in a smoother less
wrinkled appearance)
__ SPIDER VEIN TREATMENT (via Jaser or
sclerotherapy)
__ OBAGI (prescription strength skin care products that
transform your skin at the cel1ular level to look younger
and healthier)
Signature _____________
Date ___
Thank you for taking the time to complete this questionnaire_ The information you have prolided will help us to provide the best care for YOlt Bv signing above you authorize the release of medical information necessary to process insurance claims you (Juthori-e Dr Johnson to bill your insurance company for medically necessary services and you request payment ofMedicare benefits and insurance benefits directly 10 Brian T Johnson MD for the submission of those claims_ lOU also arree to Jtll all charges not covered hy our insurance
You understand and agree that all oifice visits charges and services are payable on fhe day 5Prvice is rendered You authorize the release of all medical records tofrom Brian T Johnson MD dba Trinitv Dermatologv alld Aesthetic Centre_
727-264-8825 TRINITY AESTHETIC CENTRE
Brian T Johnson MD PA Laser Non-Surgical amp Cosmetic Dermatology
MARIJANA CEJKOVA PA-C bull TONYA TERWilliGER PA-C
1805 Cypress Brook Dr 101 Trinily FL 34655
Corner of Trinity Blvd and Duck Slough www_trinitydermflcom
Second LO(-Ilioll
New Pon Richey 727-8 J5-9878
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TRINITY AESTHETIC CENTRE Laser Non-Surgical amp Cosmetic Dermatology
MEDICAL HISTORY Reason for todays visit _______________
Are you experiencing any of the following problems
Please list all allergies (medicines anesthetics antibiotics pain
medications) ________ __ __ ____________________________
--_ __--- shy
Are you sensitive or allergic to
Y N Penicillin
Y N Local Anesthetic (eg Lidocaine)
o Check here if you have no known allergies to medications
Please list all CUiTent medications
_----__ _ __-------------- --- shy
Are you taking
Y N AspirinltJotrin
Y N Cortisone Steroids
Y N Anticoagulants ( blood thinners)
Y N Trcmquilizers or Sedatives
Y N Insulin
Y N Herbal Supplcments ______ _
Any over the counter medications) If so please 1ist
Ched here if you are not taking any medications
Do you have a family History IFH) of
Skin Cancer __Basal Cell __Squamous Cell
rvleh1JlOm~1
Which family member ______ _____ _
Dysplatic Nemiddotj (Moles)_
FH of lny Olher Sin Disorders)
lOUT Per~onal HilOrv
HABITS
y N Sm()kin~ hjJJcksday ___________
Jf former smoker daie quit _________
Y N Drllgs nov or in plSI Type ________ _
y N n~ lli or mighl VOL be pre~nJJlt
_ Bbal Cell __ Sqlltlrnou ~ CltII
Y N New or Changing Skin Lesions
Y N Hair or nail changes
Y N Excessive scarring I keloids
Y N Skin Pigment problems Y N Fever BlistersCold Sores Y N Poor Wound Healing Y N DizzinessFainting tendency Y N Seizures IStrokes Y N High Blood Pressure Y N Double Vision I Dry Eyes Y N Kidney IBladder problems Y N Vaginal bleeding Y N Heavy periods Y N Excessive weight gain loss Y N DepressionMental Illness Y N Alcohol i Dmg abuse Y N Diabetes Y N Wear Glasses Contacts Y N Glaucoma Y N Thyroid condition Y N Abnormal response to cold y N Chronic infections Y N AlDS I HN positive Y N Heart Attack Angina Y N Pacemakerl
Y N Cranlping when walking
Y N History of blood clots in veins
Y N Trouble swallowing
Y N Nausea Vomiting Y N Heartburn I Ulcers Y N Blood in stools Y N Abdominal pain Y N Liver problemsHepatitis Y N ConstirationDiatThea Y N Temporary blindness Y N Easy bruisingBleeding Y N Anemia or blood disorder Y N Bleeding gums Y N Chronic cough Y N Blood in sputum Y N WheezingiSh0l1ness of breath Y N Tuberculosis Y NAsthma Y N Sinus or hay fever Y N Chest pain Y N PalpiLations Y N Hcal1 murmur Y N Breast pail1 or lumps Y N Anificial Valve or Joints
------- shy
Please Jist all of your medical illnesses (diahetes hypenen~ion heltlrt disea~e lung di seases etc)
o Check here if you hltlve no pat medical illnesses Please list all surgeries you have had done and the month and ~ ear these were performed ____--____- _ _-___ __------ ____-_____--__-shy__ _
o Check here if you have never had surgery before
Current Skin Care Facial cleanser iv1oi~lurizer ___ ____ --_ __ __-_ __ _- shySunscreen ________ SPf _ _______ Cosmetics __________________ _
PIe~It cirLl e if you Ire currenlly using hcc prndUi h
CilYloli t aid Y N Rctin-A YN AcclJlJne Y N n YO I CltlTCDtly cxpfricncing
R(Jlie l((iJing __ lrritalinn Buming LOcIlJ()n _ ______________________
- ---------
TRINITY AESTHETIC CENTRE Laser Non-Surgical amp Cosmetic Dermatology
MEDICAL HISTORY Reason for todays visit _______________
Are you experiencing any of the following problems
Please list all allergies (medicines anesthetics antibiotics pain
medications) ________ __ __ ____________________________
--_ __--- shy
Are you sensitive or allergic to
Y N Penicillin
Y N Local Anesthetic (eg Lidocaine)
o Check here if you have no known allergies to medications
Please list all CUiTent medications
_----__ _ __-------------- --- shy
Are you taking
Y N AspirinltJotrin
Y N Cortisone Steroids
Y N Anticoagulants ( blood thinners)
Y N Trcmquilizers or Sedatives
Y N Insulin
Y N Herbal Supplcments ______ _
Any over the counter medications) If so please 1ist
Ched here if you are not taking any medications
Do you have a family History IFH) of
Skin Cancer __Basal Cell __Squamous Cell
rvleh1JlOm~1
Which family member ______ _____ _
Dysplatic Nemiddotj (Moles)_
FH of lny Olher Sin Disorders)
lOUT Per~onal HilOrv
HABITS
y N Sm()kin~ hjJJcksday ___________
Jf former smoker daie quit _________
Y N Drllgs nov or in plSI Type ________ _
y N n~ lli or mighl VOL be pre~nJJlt
_ Bbal Cell __ Sqlltlrnou ~ CltII
Y N New or Changing Skin Lesions
Y N Hair or nail changes
Y N Excessive scarring I keloids
Y N Skin Pigment problems Y N Fever BlistersCold Sores Y N Poor Wound Healing Y N DizzinessFainting tendency Y N Seizures IStrokes Y N High Blood Pressure Y N Double Vision I Dry Eyes Y N Kidney IBladder problems Y N Vaginal bleeding Y N Heavy periods Y N Excessive weight gain loss Y N DepressionMental Illness Y N Alcohol i Dmg abuse Y N Diabetes Y N Wear Glasses Contacts Y N Glaucoma Y N Thyroid condition Y N Abnormal response to cold y N Chronic infections Y N AlDS I HN positive Y N Heart Attack Angina Y N Pacemakerl
Y N Cranlping when walking
Y N History of blood clots in veins
Y N Trouble swallowing
Y N Nausea Vomiting Y N Heartburn I Ulcers Y N Blood in stools Y N Abdominal pain Y N Liver problemsHepatitis Y N ConstirationDiatThea Y N Temporary blindness Y N Easy bruisingBleeding Y N Anemia or blood disorder Y N Bleeding gums Y N Chronic cough Y N Blood in sputum Y N WheezingiSh0l1ness of breath Y N Tuberculosis Y NAsthma Y N Sinus or hay fever Y N Chest pain Y N PalpiLations Y N Hcal1 murmur Y N Breast pail1 or lumps Y N Anificial Valve or Joints
------- shy
Please Jist all of your medical illnesses (diahetes hypenen~ion heltlrt disea~e lung di seases etc)
o Check here if you hltlve no pat medical illnesses Please list all surgeries you have had done and the month and ~ ear these were performed ____--____- _ _-___ __------ ____-_____--__-shy__ _
o Check here if you have never had surgery before
Current Skin Care Facial cleanser iv1oi~lurizer ___ ____ --_ __ __-_ __ _- shySunscreen ________ SPf _ _______ Cosmetics __________________ _
PIe~It cirLl e if you Ire currenlly using hcc prndUi h
CilYloli t aid Y N Rctin-A YN AcclJlJne Y N n YO I CltlTCDtly cxpfricncing
R(Jlie l((iJing __ lrritalinn Buming LOcIlJ()n _ ______________________
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