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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

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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 _ ______________________