Good Faith Exam Note: this is a confidential record of your medical history. Information collected here is for the sole use of Skin Deep. Information collected here will not be released to any person without your written authorization. Orders for prescription-strength products cannot be completed without these forms.Which of the following prescription products would you like to purchase? Check all that apply:* Biafine Trolamine Topical Emulsion Latisse Obagi Nu-Derm Blender Obagi Nu-Derm Clear Obagi Nu-Derm Transformation Kit (any size) Obagi Tretinoin Cream (any strength) Skin Deep Hydroquinone Powder Refissa (any size) None of these Personal and Contact Information:Patient's Name*Email* Home Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Alternate PhoneWork PhoneOccupationSex*MaleFemaleYour Health:Within the last year, have you been under a dermatologist’s or other physician’s care?*YesNoIf yes, please specify:Do you have a history of cold sores?*YesNoPlease list your current medications, or state "none":*Have you started any new medications since the last time you filled out this form?*YesNoTell us about any allergies that you have, or state "none":*Do you smoke?*YesNoConsume alcohol?*YesNoDo you visit a tanning salon?*YesNoDo you exercise?*YesNoDo you follow a restricted diet?*YesNoDo you wear contact lenses?*YesNoDo you have metal implants, a pacemaker or body piercings?*YesNoRate your level of stress on a scale of 1 to 5 (1 = low stress, 5 = high stress)*Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks?)*YesNoYour Skin:Do you use SPF (sunscreen)?*YesNoIf yes, indicate what SPF you use on your face and/or body:Do you burn easily in moderate sunlight?*YesNoDo you have a tendency to redness?*YesNoDo you ever experience burning, itching or stinging sensations on your skin?*YesNoHave you ever used any of the following? Check all that apply:* Retin A Hydroquinone Accutane Zovirax Valtrex None of these If yes to any of the above, explain any negative reaction:Have you ever had any of these procedures? Check all that apply:* chemical peel waxing electrolysis facial surgery none of these If yes to any of the above, explain any negative reaction:Describe your specific concerns/challenges with your skin, or state "none":*Which of these do you currently use for your face? Check all that apply:* soap cleanser toner moisturizer masque exfoliator eye products none of these For your body? Check all that apply:* soap shower gel scrubs oil moisturizer depilatory products self-tanners none of these Are you currently using any products that contain the following ingredients? Check all that apply:* glycolic acid lactic acid any exfoliating scrubs any hydroxyl acid products Vitamin A derivatives (i.e., Retinol) none of these Do you ever experience these conditions on your skin?* flakiness tightness obvious dryness none of these Female Clients:Are you pregnant or lactating?*YesNoNot Applicable - Male PatientAre you taking oral contraceptives?*YesNoNot Applicable - Male PatientAre you currently having or due for your menstrual period?*YesNoNot Applicable - Male PatientMale Clients:Do you have any shaving challenges? If yes, specify, or state "none":*Please sign and date the form:Patient Signature*Date* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms. HIPAA Patient Form The following is a required "notice of privacy practices" (NPP) in keeping with Federal and State HIPAA requirements.Overview of privacy issues:The laws regarding privacy of personal health information are complicated. Federal regulations require your approval of a full NPP as part of receiving health services. To accomplish this, I will provide you with a copy of the full, legally required NPP and this shorter version, which summarizes the same information. Finally, there is a standard consent form that documents your agreement with the NPP. I am not permitted to provide treatment without an executed consent form. You also may have additional questions or concerns, including about situations not covered by this information, and you are encouraged to voice these. The health information in your records will be mainly used to provide treatment, to arrange payment for services, and for some other business activities that are called, in the law, "health care operations." Before private information can be disclosed (sent, shared, or re1eased) for any additional purposes, a separate authorization form is required to allow it.Your health information is private and will be kept that way, but there are some times when the law requires disclosure. For example: 1. When there is a serious threat to your health or safety or the health or safety of another individual or the public. Information would then be shared with a person or organization that is able to help prevent or reduce the threat. 2. Some lawsuits and legal or court proceedings. 3. If a law enforcement official requires to do so. 4. For Workers Compensation and similar benefit programs. 5. There are some other situations like these but which happen very rarely. They are described in the longer version of the NPP. Your rights regarding your health information: 1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place for more privacy. For example, you could ask me to call you at home and not a work to schedule or cancel an appointment. I will try my best to do as you ask. 2. You can request that I limit what is disclosed to any people who are involved in your treatment or the payment for treatment, such as family members or friends. If I agree to the request, I would attempt to keep that agreement except if it is against the law, or in an emergency, or when the information is necessary to treat you., 3. You have the right to look at your health information, such as billing records or health records associated with your skin care. You can even get a copy of these, provided that you reimburse your provider for time and copy expenses involved. 4. If you believe that any information in your records is incorrect or missing important information, you can ask to have some kinds of changes (termed "amending") to your health information. You would have to make such a request in writing and send it to the office, and you would also need to write the reasons that you want to make the changes. 5. You have the right to a copy of this notice and to the longer NPP. If I make any changes to either form, I will post the new version in the waiting room, and you could always get a copy of the new NPP from me. 6. You have the right to file a complaint if you believe that your privacy rights have been violated. You can file such a complaint with me personally and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint regarding privacy will not in itself change the health care that you receive at this office. If you have any questions regarding this notice or the health information privacy policies at this office, please contact Skin Deep, or go to https://www.hhs.gov/hipaa/for-professionals/faq/index.html to find out more information.Patient's Name* First Last Email* Phone*The effective date of this notice is:* Date Format: MM slash DD slash YYYY I have read and understand the above Notice.Patient Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.