Client Registration Form

Date

Patient Name

First Name

Middle Name

Last Name

Name you prefer to be called

Address

Date of Birth

Sex

Male

Female

Age

Home Phone Number

Cell Phone Number

Work Phone Number

Ext

I prefer to be contacted at my home / cell / work phone number (please indicate).

E-mail address

Name and address of your Primary Care Physician

If the patient is a minor, name and address of parent or guardian

HOW WERE YOU REFERRED TO SEACOAST REJUVENATION CENTER?

Yellow pages

web site - www.seacoastrejuvenation.com

Newspaper

Other web site

Friend or relative

TV

Physician

Other

Mailing or newsletter

Please specify

CONSENT TO BE PHOTOGRAPHED

I consent to be photographed before, during and after my treatment. I understand that these photographs shall be the property of Seacoast Rejuvenation Center as a part of my permanent patient record.

Signature of Patient, Parent or Guardian

Use your mouse or finger to sign in the box below.

CONSENT TO USE PHOTOGRAPHS

I understand and agree that my photographs may be used for scientific purposes, for internal patient education, publication, and presentations. I understand my identity will be protected.

Signature of Patient, Parent or Guardian

Use your mouse or finger to sign in the box below.

CONFIDENTIALITY AGREEMENT

I understand my records and photographs are strictly confidential. The contents of my records cannot be released to any person or organization without my prior written approval, excluding peer review.

Signature of Patient, Parent or Guardian

Use your mouse or finger to sign in the box below.

Client Registration Form

Client Information

Clinical Skin Evaluation

Skin Type (Fitzpatrick Classification)

Client Registration Form

Client Registration Form

Client Information

Clinical Skin Evaluation

Skin Type (Fitzpatrick Classification)

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