LHA Patient Registration Form

    Date:

    Full Name:

    Date of Birth:

    Address:

    Phone Number:

    Email:

    Occupation:

    Have you ever been treated for your mental health?
    YesNo

    Medications

    List all medications you are currently taking, both by mouth and topically, including prescriptions (such
    as birth control, blood thinners, etc.) over-the-counter treatments, vitamins, herbal supplements and
    creams.

    Are you currently, or have you recently, taken any medications containing Aspirin?
    YesNo

    How did you hear of the clinic?

    Please describe the reason for your visit today

    Would you like to receive email announcements on special discounts, products, or procedures?
    YesNo

    Medical History

    Please list any medical conditions, including skin conditions that you have previously been diagnosed with
    and/or treated for:

    Please list any previous or upcoming surgery:

    Please list any cosmetic treatments you have previously had:

    Have you been on Accutane therapy within the past 24 months?
    YesNo

    Have you taken any steroid preparation(s) over the past year?
    YesNo

    Allergies

    Do you have any allergies? please list all food and medication allergies including products such as tape,
    along with the nature of your reaction:

    Social History

    Do you smoke?
    YesNo

    Do you use sunscreen on a daily basis?
    YesNo

    Please list your current skin care products:

    Authorisation

    I hereby authorise cosmetic medical treatment of the person named above, and agree to pay all fees and charges for treatments and services rendered on the day of treatment. I understand that medical treatment may include a review of personal, social and medical history, discussion of the reason(s) for the visit(s), and will include photographs of the area(s) being discussed and or treated before and/or after treatment. The photos will not be used for promotional material. I understand that my information will be kept in accordance with the Privacy Code New Zealand 1994.

    I have read and agreed to the terms above.