4905 W. Laurel Street, Suite 202Tampa, FL 33607

WHAT BOTHERS YOU?

EYES AND UPPER FACEo DROOPY EYELIDS

o PUFFY LOWER EYELIDS

o SAGGING LOWER LIDS

o DARK CIRCLES/ UNDER EYE HOLLOWS

o EYE BROW SAGGING

o THINNING or SPARSE LASHES

o LOSING FACIAL VOLUME/FULLNESS

o FACE OR EYES APPEARS “TIRED” OR “LESS FRESH”

LOWER FACE

SKINo FINE LINES AND WRINKLES

o BLOTCHY APPEARANCE/ SUN SPOTS

OTHERo

o SAGGING JAW LINE

o SAGGING NECK

o DOUBLE CHIN (TURKEY NECK)

o FACIAL FOLDS / SHADOWS

o THIN LIPS

o UNHAPPY WITH A PREVIOUS SURGERY

NOSEo DISSATISFIED WITH SHAPE

o DIFFICULTY BREATHING

HANDS APPEAR THIN AND AGED___________________________________________________________________________________________________________________

AUTHORIZATION / ASSIGNMENT: I understand that I am financially responsible for all charges related to services received at Elite Medical.MEDICAL RECORDS: Authorization is hereby granted for release of any information required to process this claim. A copy of this authorization is as valid as the original. Authorization is hereby granted for release of pertinent information (this may include photographs, operative notes, clinic and consultation notes) to a hospital / another physician’s office for appropriate continuum of care treatment as required.PRIVACY POLICY: I acknowledge I have received / have been offered a copy of Elite Medical, notice of privacy practices and Arbitration Agreement.

Signature: ____________________________________________

Date: ________________________________________________

DEMOGRAPHIC INFORMATION

Today’s Date:

Name:

Date of Birth: Age:

Email:

Last four digits of Social Security #:

Home Address:

City State Zip

Home Phone #:

Cell Phone #:

Work Phone #:

o Single o Married o Divorced

Spouse Name:

Spouse Phone #:

Emergency Contact:

Emergency Contact #:

Occupation:

Employer:

HOW DID YOU HEAR ABOUT ELITE MEDICAL?(PLEASE CHECK ALL THAT APPLY)

Friend Patient Family Member Physician Spa/EstheticianIf so, Name: __________________________________________ May we thank them? o Yes o No

Yelp Google / Yahoo! Paper / Ad Other (Specify): _______________________________________

o

o o o

o o o o

Elite Medical may contact you by the following methods: Phone, Text, Email, or Postal Mail. Please provide wireless carrier ______________________________Preferred Pharmacy: _____________________________________Location (nearest cross streets): ______________________________________________________________________________________Phone Number: ___________________________________________

CONSULTATION AND MEDICAL QUESTIONNAIRE

MEDICAL HISTORY

Height: Weight:Family Physician: Phone Number:

DO YOU HAVE ANY OF THEFOLLOWING CONDITIONS?

(PLEASE CIRCLE ALL THAT APPLY)

Headaches Strokes Seizures Fainting SpellsHeart Disease High Blood PressureChest Pain Shortness of BreathLung Disease Thyroid DiseaseLiver Disease / Hepatitis UlcersAnemia Bleeding Problems HIV Blood Clots

Do you have any other medical problems / conditions? (Please list below)

Have you ever had surgery before? (Please list below) Type Date

List any medications you take on a regular basis (Including appetite suppressants, vitamins, herbal supplements, or any homeopathic medication) Name Dosage

***Do you have any allergies to medications?*** Name Reaction

OFFICE USE ONLY

SOCIAL HABITS

Cigarette Smoking: o Yes o No # of cigarettes / day: ___

Alcohol Use: o Yes o No # drinks / week: ___

o Yes o No

NON-SURGICAL RECOMMENDATIONS AND NOTES

OTHER o HAND REJUVENATION

o CHIN AUGMENTATION

o JAWLINE CONTOUR

NEUROMODULATOR

JUVEDERM ULTRA/ U+VOLUMAVOLLURE RESTYLANE

SCULPTRARADIESSE

KYBELLA

OTHER: ______________

______________________

______________________

______________________

SKIN ZO SKIN HEALTHEPIONCECOLORESCIENCE LATISSESKINADE

4905 W. Laurel Street, Suite 202Tampa, FL 33607

oLatex Allergy Yes o No

CONSULTATION AND MEDICAL QUESTIONNAIRE

Co n C e rn s & In t e re s t s

- What skin problems or concerns would you like to address? ......................................................................................................................................................................................

........................................................................................................................................................................................................................................................................................................................................................................

- What would you like to change about your skin? ........................................................................................................................................................................................................................

........................................................................................................................................................................................................................................................................................................................................................................

Cu r re n t He a l t H & lI f e s t y l e

- Do you follow a home skin care regimen? ❍ No ❍ Yes If Yes, check the items and identify the name of the products you use regularly:

- Have you had an allergic or irritant reaction to a skin care product(s)? ❍ No ❍ Yes Explain: .............................................................................

........................................................................................................................................................................................................................................................................................................................................................................

- Have you had facial waxing or used a depilatory in the past week? ❍ No ❍ Yes

- Have you ever had a chemical peel? ❍ No ❍ Yes If yes, which type: .......................................... , approximate date: ......................... (mo./year)

- List all the medications, oral and topical, you are currently using or have used in the past six months

- Please check if you have any of the following health conditions:

Name: _________________________________________________________

Date:________________________________________________________________________________________________

s k I n C a r e Q u e s t I o n n a I r e

❍ eye makeup remover .......................................................

❍ soap .............................................................................................

❍ cleanser .....................................................................................

❍ toner/astringent ..................................................................

❍ day cream ................................................................................

❍ night cream ............................................................................

❍ scrub/exfoliant .....................................................................

❍ mask ...........................................................................................

❍ eye cream ..................................................................................

❍ serum .........................................................................................

❍ sunscreen .................................................................................

❍ Retin-A®/Renova® ..............................................................

❍ retinol cream .........................................................................

❍ AHA product(s) ..................................................................

❍ benzoyl peroxide..................................................................

❍ skin bleacher/lightener ..................................................

❍ foundation .............................................................................

❍ other, list .................................................................................

- Do you sunbathe?❍ No ❍ Yes How often: ..................................

- Do you use a tanning booth?❍ No ❍ Yes How often: ..................................

- Do you use sunscreen regularly?❍ No ❍ Yes SPF: ....................................................

❍ Asthma/Hay Fever❍ Arthritis❍ Diabetes

❍ Cancer❍ Heart disease❍ Hepatitis

❍ Hormonalconditions

❍ Pregnancy

❍ Cold sores/fever blisters

❍ Back injuries

❍ Hip or kneereplacement

❍ Accutane®

❍ Antibiotics, (please list)❍ Steroids, topical or orally (ex: prednisone) ❍ Birth control pills

.................................................................................................................................... ❍ Other .....................................................................................................................

De rm a t o l o g I C HI s t o r y

- Have you had any cosmetic procedure or laser surgery in the past six months? ❍ No ❍ YesIf yes, please specify: .............................................................................................................................................................................................................................................................................................................

.....................................................................................................................................................................................................................................................................................................................................................................

- Do you take aspirin regularly? ❍ No ❍ Yes

- Please check if you have a history of the following health conditions:

Patient's Signature: ........................................................................................................................................................................................................................................... Date: .......................................................................................................................

Please note: It is extremely important to inform us during the course of your treatment of any changes in the usage of all medications including Accutane®, Retin-A® and other prescribed topical medications. It is for your protection andsafety. Thank you for answering our questions. The information in this questionnaire is strictly confidential.

s k I n C a r e Q u e s t I o n n a I r e

- Are you required to take antibioticsprior to surgical or dental procedures?❍ No ❍ Yes

- Any known allergies to local anesthetics or medications?❍ No ❍ Yes If yes, please explain: ............................................................................................................................

.......................................................................................................................................................................................................................................

- When did you last see a dermatologist?❍ Never❍ 6 Months❍ 1 Year❍ 2 Year

- What types of skin care treatments have you had?Treatment Howlongago

...................................................................................................................... .......................................................................................................

...................................................................................................................... .......................................................................................................

...................................................................................................................... .......................................................................................................

O-1 07/18,V.1

❍ Bleeding Problems❍ Skin Cancer❍ Stomach Ulcers

❍ High Blood Pressure

❍ Hives❍ Tuberculosis

❍ Herpes❍ Heart Murmur❍ Cardiac

Pacemaker

❍ Eczema❍ Fainting Spells❍ Other ..........................................................

Notes:

Elite Medical, PLLC; All rights reserved 2016

FitzpatrickSkinTypeWorksheet

Name:Date:Score 0 1 2 3 4

Whatisthecolorofyoureyes?

LightBlue,GrayorGreen

Blue,Gray,orGreen

Blue

DarkBrown

BrownishBlack

Whatisyournaturalhaircolor?

SandyRed

Blond

Chestnut,

DarkBlonde

DarkBrown

Black

Whatisthecolorofyour

unexposedskin?

Reddish

VeryPale

PalewithBeigeTint

LightBrown

DarkBrown

DoyouhaveFrecklesonSunexposedareas?

Many

Several

Few

Incidental

None

Whathappenswhenyoustay

inthesuntolong?

PainfulRedness,Blistering,Peeling

BlisteringFollowed

BurnssometimesfollowedbyPeeling

RareBurns

NeverhadBurns

Towhatdegreedoyou

turnBrown?

HardlyorNot

atall

Lightcolor

Tan

Reasonable

Tan

TanVeryEasily

TurnDarkBrownQuickly

Doyouturnbrownseveralhours

aftersunexposure?

Never

Seldom

Sometimes

Often

Always

Howdoesyourfacerespondto

theSun?

VerySensitive

Sensitive

NormalVery

ResistantNeverhadaProblem

Whendidyoulastexposeyourselftothesuntanningbed

orself-tanningcreams?

Morethan3Monthsago

2-3Months

ago

1-2Months

ago

LessThan1Monthago

Lessthan2Weeksago

Doyouexposetheareatobetreatedtothesun?

Never

HardlyEver

Sometimes

Often

Always

TotalScore:

Score0-78-1617-2526-30Over30

FitzpatrickSkinType:IIIIIIIVV-VI

Notes:

Arbitration Agreement

Preface: Elite Medical, herein after referred to as the Practice (“Practice”) institutes this Arbitration Agreement, herein after referred to as the Agreement ("Agreement"). This document should be read carefully and fully understood before signing. Article 1: Agreement to Arbitrate: It is understood that my dispute as to medical malpractice that is, as to whether any medical services rendered under this contract were unnecessary, authorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by the Florida Arbitration Code, and not by a lawsuit except as Florida law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this Agreement bind all parties whose claims may arise out of or related to treatment or services provided by the physician, Nurse Practitioner, Registered Nurse, Physician Assistant, Medical Aesthetician, or Medical Assistant, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of a pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider’s, and the employees, associates, association, corporation or partnership, and the employees, agents and estates of any of them must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by Elite Medical to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties and must be made within the time frame set forth in the applicable state statute dealing with medical malpractice. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of demand for neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees to the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefits. Arbitration shall take place within 30 days after the completion of discovery as provided in the Florida Rules of Civil Procedure and the decision of the arbitration panel shall be binding upon the parties for all purposes. The time for responding to discovery requests shall be 10 days. All discovery shall be completed within 2 months after the appointment of the panel of arbitrators, unless the time for discovery is extended for good cause by the panel. The arbitration panel shall decide any disputes regarding discovery. The arbitration panel is expressly authorized to award all reasonable fees and costs, including attorney's fees, to the prevailing party against any party who has violated this Agreement. The parties agree that the arbitrators have the immunity of a judicial officer for civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law provisions. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be proper additional party in court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

Article 4: General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable Florida statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for the arbitrators shall be governed by the Florida Rules of Civil Procedure provisions relation to arbitration. Article 5: Please be aware that this practice, under the title of a professional limited liability corporation (PLLC) with sole proprietorship, does not participate in Medicare, Medicaid, private insurance, or public insurance exchanges. This organization solely engages in a fee for service structure that the patient is directly responsible for and does not involve any third parties. As such, this organization is not defined as a covered entity as described by the Centers for Medicare and Medicaid Services (CMS) or by the Affordable Care Act (ACA) provisions. Furthermore, though this organization is not bound by the rules and regulations of HIPPA, we align our practice with the same principles and diligently safeguard your personal data and medical information. Article 6: If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect and shall not be affected by the invalidity of any other provisions. I understand that I have the right to receive a copy of this Arbitration Agreement. _____________________________________ ________________________ Patient Signature Date _____________________________________ Patient Name Printed _____________________________________ _________________________ Elite Medical Representative Date