PATIENT GENERAL INFORMATION AND MEDICAL / SURGICAL HISTORY

In order for the physicians of Capital Laser and Skin Care to provide you with the most effective and safe treatments, kindly fill out this form as accurately as possible

Phone (Check the preferred number to reach you)

If Cancer is checked

Personal Habits

By placing my signature below, I freely give Dr. Elizabeth Tanzi, Dr. Geeta Shah, Dr. Tania Peters and the other healthcare providers at Capital Laser and Skin Care permission to treat my condition. I understand that I will be charged or billed for consultations, treatments, and missed appointments per office policy.

Due to the cosmetic nature of many of our procedures, those patients covered by MEDICARE should note that their procedures will not be covered and that they are solely responsible for all related consultation and treatment fees.

I consent to the taking of medical photographs as prescribed by my treating physician. I understand that they will be accorded the same privacy as my medical chart. I further understand that baseline (pre-treatment) and follow-up photographs are essential in order to document my clinical progress and response to treatment.

I understand it is my responsibility to notify the office in writing with any changes to the information on this form.

A signature below confirms that correct patient information has been provided and that the policies of the Capital Laser and Skin Care are understood and agreed upon.

Clear

Aesthetic Needs Assessment

Please complete this questionnaire to help us better understand your aesthetic needs and concerns. During your consultation, your responses will help us identify personalized treatment options.

List any aesthetic treatments and procedures, if any, have you had in the past? (Check where appropriate & add date of last treatment)

Treatment

Surgical Procedures

Treatment

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