www.thriveportland.com - New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.

General Patient Information

Patient Name :

First NameMiddle NameLast Name

Date of Birth :

Age :

Occupation :

Address :

Street Address

Street Address Line 2

CityState

Zip Code

Home Phone # :

Work Phone # :

Cell Phone # :

Email Address :

Emergency Contact Details

Contact Person Name :

Phone # :

Relationship of Contact :

How did you hear about us :

Patient Health History

Do any of the things listed below apply

Are you pregnant ?

Are you nursing ?

Trying to get pregnant ?

HIV/AIDS ?

History of hypertrophic/keloidal scaring

Psoriasis

Lupus

Sun rash or photo allergic

Recent exposure to sun/tanning booths

Recent use of sunless tanning cream

Do you freckle in the sun

Epilepsy

Cancer / Melanoma

Family history of cancer/melanoma

Diabetes

Herpes/Cold Sore

Folliculitis

Pigmentation Disorder

Heart Problems

Pacemaker

Date of last period

Irregular Periods

Menopausal Symptoms

Total Hysterectomy

Polycystic Ovarian Cancer

Adrenal Hyperplasia

Other metabolic diseases

Recent increase in hair amount/growth

Relatives with excessive hair

High Stress Level

Dental Fillings/Metal Pins

Cosmetic Tattoos

Taken Accutane in the past year

Use Retin A or Alpha/Beta Hydroxy Acids

Allergic to Lidocaine /other anesthetics

Allergic to Vitamin B

History of Hives

St. John’s Wort or Vitamin E use

Do you drink alcohol

Do you smoke

Are you currently under a physician’s care or have any conditions not listed above?

Please describe the nature of your visit and what you would like to accomplish with your treatment.

What medications do you take? (Please include any vitamins, herbal remedies, over the counter supplements)

Please list allergies. (Include prescription medications, over the counter medications, soy, and environmental allergies)

Have you ever undergone any cosmetic surgery, peeling procedure, dermabrasion, or any other laser treatment?

If yes, what type and how long ago?

Check the description that would best describe you if you were exposed to strong sun with no sun block.

For Laser Hair Removal Patients: What is your current form of hair removal?

What skincare products are you currently using?

Cosmetic Interest Questionnaire

To help us better understand your goals please complete this questionnaire. This is optional.

What’s your actual age?

What age do you feel others perceive you as?

Check the Prefered Answer (5 – Most concerned, 1 – Less Concerned)

I feel that other people perceive me as looking angry, sad, or tired, even when I’m not.

I feel that the length and thickness of my eyelashes is not what it once was.

As I’ve gotten older, I’ve noticed that the color, tone, and texture of my skin has gone downhill.

As I’ve aged, I’ve become more concerned with the appearance of fine lines and wrinkles around my eyes and forehead.

Other than the services we are seeing you for today, what additional services Would you like to learn about? Please click all that apply.

Refund Policy

Services:

All services need to be completed within 12 months from purchase/start date.

Our knowledgeable Thrive staff is always available to answer any questions you may have, please make informed purchases as no refunds can be made. We will gladly issue a Thrive credit toward future services upon approval of management.

Products:

Any unopened products returned with a receipt within 7 days may be issued a refund.

In general, products that have been opened may not be returned. Any exceptions are up to management’s discretion.

Cancellation Policy:

48 Hour notice is required; otherwise a cancellation fee may be applied.

Patient / Legal Guardian Name

Date :