Patient Registration Forms

Physician Appointment Forms

Please print the following forms:

• Patient Information and Health History Form
• Electronic Prescriptions
• Acknowledgement of Notice of Privacy Practices and Patient Communication Authorization
• Financial Policy and Insurance Authorization
• Notice of Privacy Practices (PDF read only)
• Financial Policy (PDF read only)

We must have the insured’s date of birth and social security number. If you do not give out your social
security number, please let us know. However, there are no exceptions for the date of birth of the insured.
We require this information in order to file claims in a timely manner.

You will need to bring these forms to your appointment, along with an insurance card and photo
identification.

IPL Consultation
Please print the patient information and consent form. We require a signed consent form at the time of consultation to ensure that you have read the form and that all your concerns have been addressed. Signing the consent does not mean that you must have treatment.

• Patient Information Form
• Informed Consent

Laser Hair Removal Consultation
Please print the patient information and consent form. We require a signed consent form at the time of consultation to ensure that you have read the form and that all your concerns have been addressed. Signing the consent does not mean that you must have treatment.

• Patient Information Form
• Informed Consent

Microdermabrasion Treatment
Please print the patient information and consent form. We require a signed consent form at the time of consultation to ensure that you have read the form and that all your concerns have been addressed. Signing the consent does not mean that you must have treatment.

• Patient Information Form
• Informed Consent

We participate in the following plans:

Prescription Refills

To request a prescription refill please contact your pharmacy and ask them to fax us a refill request to
(847) 272-4434 or send it electronically.

For products purchased in our office please call our office at (847) 272-4433.