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Microsoft word - laser nail treatment form

Last Name:______________________________________ First Name:____________________________ M.I.:______ Address:__________________________________City:____________________State:_____________ Zip:__________ Home Phone:(________)_________________________ Cell Phone:(______)__________________________ Email Address: _________________________________________________________________ Emergency Contact:________________________________ Phone:_______________________ How did you hear about our clinic? __________________________________________________ 1. Are you here today for a Nail Fungus problem? ( ) Yes ( ) No 2. How long have you had this problem? _________(Months) (Years) 3. Has this condition been treated before? ( ) Yes ( ) No 4. Check all that you have used or tried: How long? ________ Last time used: _________ How long? ________ Last time used: _________ How long? ________ Last time used: _________ How long? ________ Last time used: _________ How long? ________ Last time used: _________ How long? ________ Last time used: _________ How long? ________ Last time used: _________ How long? ________ Last time used: _________ How long? ________ Last time used: _________ How long? ________ Last time used: _________ 5. Do you have any of the following conditions? (Circle all that apply to you) ( ) None Other:_____________________________________________________________________________________ 6. Are you currently pregnant? ( ) Yes ( ) No 7. List any medications you are now taking: ( ) None ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 8. List any medications you are allergic to: ( ) None ____________________________________________________________________________________________________________________________________________________________________________________________________ 9. Do you get pedicures at Nail Salons? ( ) Yes ( ) No If so, how often? ______ 10. Do you have any other foot problems? ( ) Yes ( ) No If so, what are they? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 1724 NE 42nd Ave Portland, OR 97213 Oregon Natural Medicine, LLC www.OregonNaturalMedicine.com P: 503-946-8700 F: 503-339-9500 I hereby voluntarily request and willingly consent to receive laser treatment, physical examinations and diagnostic procedures
by the Physicians and Healthcare Practitioners at Oregon Natural Medicine, LLC. I understand that the Physicians and
Healthcare Practitioners will only be treating me for nail fungus. I understand that I must schedule a separate Naturopathic
Medical Appointment for conditions beyond fungal nail treatment.
Appointments:I understand that Oregon Natural Medicine, LLC has 24 hours advance notice cancelation policy. If you miss
your appointment or cancel with less than 24 hours, we will charge your account $50. This fee will be waived for emergency
situations.
Effectiveness: I understand that laser nail treatment is generally very safe and effective, but I realize that there is no guarantee
of cure for my medical condition.
Pregnancy: I understand that laser treatment is contraindicated for pregnant women. I will inform my healthcare practitioner
at Oregon Natural Medicine, LLC if I am pregnant, if there is a chance that I may be pregnant, or if I am lactating.
Additionally, I understand that certain nutritional and herbal supplements may be harmful to pregnant women and/or their
unborn child
Insurance Coverage: I understand that laser nail treatment is considered an Aesthetic procedure and is not covered by health
insurance. I understand that my health insurance will not be billed and it is my responsibility to pay at time of service for this
procedure.
Privacy Policy: I understand that my medical record will be kept private. I understand that the Clinical and support staff at
Oregon Natural Medicine, LLC will have access to my medical record. I acknowledge that my information will never be
disclosed to anyone without my consent, except in the case where it is mandated by state law. I understand that I have the right
to view my medical chart
Possible Risks and Complications: I am aware that there are risks and possible complications associated with all medical
treatment, including the operation or procedure as outlined above. I understand that some of the risks and complications
include: discomfort during treatment, usually a “snapping” sensation, crusting or blistering (of skin) immediately following
treatment, redness, pain and/or swelling in treated areas immediately following treatment, discoloration of the skin, including
lightening or darkening, in the treated area, mild surface scarring or changes in skin texture over the treated areas.
I agree to contact the a staff member of Oregon Natural Medicine, LLC immediately if I believe any adverse reaction may be
occurring due to the treatment that was recommended or performed at this clinic. I will inform my healthcare practitioner of
any previous allergic reaction I have had to any pharmaceutical, nutritional supplement, herbal supplement, homeopathic
supplement or topical medicine.
Supplements and Products: Thank you for supporting local business by purchasing your high quality nutritional supplements
and products at Oregon Natural Medicine. We strive to keep our prices affordable. In purchasing through Oregon Natural
Medicine I understand that they are unable to refund any purchased product once it has left their premises.
Consent to be Photographed: I hereby consent to have the treatment site(s) photographed before, during, and/or after
treatment, and that these photographs shall be the property of Oregon Natural Medicine, LLC, and may be published on our
website or displayed in print or electronic media. Identifying information will be concealed.
By signing this form, I agree to the above statements. Printed name of Patient: _________________________________________________________ Signature of Patient: ___________________________________________ Date: __________________________ 1724 NE 42nd Ave Portland, OR 97213 Oregon Natural Medicine, LLC www.OregonNaturalMedicine.com P: 503-946-8700 F: 503-339-9500

Source: http://www.oregonnaturalmedicine.com/wp-content/uploads/2012/06/Laser-Nail-Treatment-Form.pdf

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