4632 Sawmill Road Columbus, OH 43220 | (614) 545-2002
NEW PATIENT PAPERWORK 

Name _______________________________________________________________ 	Date of Birth ________________________
	Last		            First			         Middle
Address ______________________________________________________________ 	Home Phone ________________________
City _____________________________________   State _______   Zip ___________ 	Cell Phone __________________________
Employer _____________________________________________________________	Occupation __________________________	
Marital Status _______________________       Gender:   M     F     Other 	Preferred Pronoun____ Language:___________________ 
 Which category best describes you?  (Select all that apply.)

 White
 Hispanic, Latino or Spanish origin 
 Black or African American
   Asian
 American Indian or Alaska Native	
 Native Hawaiian/Other Pacific Islander
 Some other race, ethnicity or origin                
Emergency Contact Name __________________________________ Relationship______________      Phone ________________

We’d love to stay in contact.  We use digital communication to confirm appointments, correspond, & make patients aware of specials and coupons.   (This information is strictly for in-office use only. We do not sell your info.)   

Email Address: 					            Social Media Usernames (Facebook/Twitter/Instagram):  
_____________________________________________        ________________________________________________________

How did you hear about Monarch Aesthetic Medicine? (Choose from options below) 

 Facebook		 Instagram				
 Google Ad/Search	 Another Patient
 Groupon		 Other _________________	 Friend/Relative _________________________________________
Please list so we can thank them.

Preferred Pharmacy:  ________________________ Address: _________________________________Phone:___________________

Past Medical History                   Have you had, or do you currently have, any of the following? (Y=yes, N= no) Circle all that apply
Myasthenia Gravis   Y  N	High Blood Pressure    Y  N	Keloid former             Y  N	Hepatitis A, B, or C      Y  N	
Cold Urticaria            Y  N	Cryoglobulinemia         Y  N	Epilepsy/Seizures       Y  N	Guillain Barre               Y  N	
Post-herpetic Neuralgia  Y  N	High Cholesterol           Y  N	Glaucoma                    Y  N	Pancreatitis              Y  N	
Diabetes                     Y  N	Kidney/Liver Disease             Y  N	Cold Sore                      Y  N	HIV                                  Y  N	
Bleeding/Clotting Disorder/Blood Thinner   Y  N	Thyroid Disease/cancer       Y  N	Obesity                         Y  N           Autoimmune Disease  Y  N	

List all hospitalizations/surgeries and dates:		  	 List current medications/vitamins/herbs with dosage:
________________________________________________	   ____________________________________________________
________________________________________________	   ____________________________________________________
________________________________________________	   ____________________________________________________
List all known allergies: (drugs, foods, environmental)   __________  Are you Currently Pregnant?_______________________
Do you drink caffeine?  No   Yes   ____ drinks per day	Do you drink alcohol? No   Yes  ____ drinks per day/week/month
Do you use tobacco products?    No    Yes   (what brand & how much?) _______________________________________ 
Have you used recreational substances in the last two years?   No    Yes  ______________________________________
Do you have metal implanted in your body? Pacemaker? Defibrillator? No    Yes         

In order to secure an appointment for a cosmetic procedure, a deposit of 50% of the full cost of the procedure(s) is required. I understand that $50.00 of this deposit is  non-refundable if I fail to arrive for my scheduled appointment, cancel, or reschedule with less than 24-hour notice. Once a package of services in initiated, no refund will be issued. No refund will be issued on services  rendered. All product sales are final. I have read and agree to the above policies.
_____________________________________________________________		_________________________		
Patient Signature									Date	

4632 Sawmill Road
Columbus, OH 43220
614-545-2002

Important Notice Regarding the Privacy of your Health Information

Your privacy is important to us.  We create information about you so we may provide you with quality care.  We are committed to protecting this information.  The Notice of Privacy Practices describes your rights with regard to your health information as well as how we may use your health information and how we must protect the confidentiality 
of your health information.  This is a summary of the more detailed information contained in our Notice of Privacy Practices:

Your rights include:

·	A right to inspect a copy of your medical information
·	A right to amend your health information
·	A right to request restrictions on what information we use or how we disclose your health information
·	A right to receive a paper copy of our Notice of Privacy Practices

These rights have special restrictions, so it is important that you read the full Notice.

It is the policy of Monarch Aesthetic Medicine to provide a safe and confidential environment for all patients.  All areas in the office, including the waiting room, reception areas, hallways, exam rooms and laboratories will be maintained in an effort to provide patient privacy during interviews, examinations, treatments and consultation.  

We may use your health information and/or records to:

·	Plan for your care
·	Help your health care providers communicate and work together to care for you
·	Submit bills to pay for your care
·	Help health care payors make sure services were actually provided
·	Help improve the quality of health care.  
·	Disclose information to certain officials or organizations when we are required to do so by law.

We encourage you to carefully read the Notice and ask to speak with the staff of Monarch Aesthetic Medicine if you need more information.  

I have been offered the Notice of Privacy Practices for Monarch Aesthetic Medicine:

Printed Name: ___________________________________________

Signature: _______________________________________________    Date: _______________
(Patient, Parent or Guardian)

4632 Sawmill Road Columbus, OH 43220 | (614) 545-2002

Financial Policy

Your clear understanding of our financial policy is important to our professional relationship. Please understand that payment of your services is considered part of your overall treatment. Your signature acknowledges understanding and acceptance of the following statements:

Required at Check-In

Each time you check in for your appointment you may be required to:
·	Verify personal contact information
·	Pay any outstanding account balance

Administrative Fees and Account Balances

·	Missed Appointments - Patients who do not attend their scheduled appointment or who cancel appointments with less than a 24-hour notice will be charged $25.00-$50.00 for each missed appointment depending on the time booked.

·	Medical Records – Patients requesting copies of medical records for dates of service on or after February 1, 2018 will be charged a fee according to HIPAA and Ohio State Law (see ORC 3701.741). 

·	Returned Check Fee - A $35.00 fee will be assessed for each returned check.

·	Collection Charges - Accounts that are not paid in a reasonable amount of time may be sent to an external collection agency and reported to the credit bureau. In addition to your outstanding balance, which may include billing fees, a 33% surcharge will be added to cover our costs and you may be dismissed from the practice if your account is sent to collections.

·	50% of the total cost of treatment on regular priced services is required prior to scheduling. The remaining balance is to be paid on the day of the treatment (if a series of treatments are to be completed, payment in full must be paid on arrival the day of the 1st treatment). Monthly specials are good for their valid calendar month only, and must be paid in full prior to scheduling and before the end of the month that the special is being run. Event prices, or individualized packages with special discounts are valid the day of the event or consult only and payment in full is required to be made the same day in order to secure the special pricing. Any and all payments made for services at Monarch Aesthetic Medicine are non-transferable and cannot be combined with any other offers, discounts, gift cards, or promotions. $50 of this deposit is  NON-REFUNDABLE UNDER ANY CIRCUMSTANCES if the service is cancelled and a refund of the prepayment is requested.  Once a series of treatments has commenced, NO refund will be issued.  No refund will be issued on any services rendered.  All product sales are final. The patient understands there is a possibility of an imperfect cosmetic outcome and realizes aesthetic medicine is an art and no human being is entirely symmetrical pre or post procedure.  All product sales are final. The patient understands a $25 charge will be incurred for cancelled appointments without a 24 hour notice.

I understand and agree to abide by the above policies and procedures as outlined in the Monarch Aesthetic Medicine Financial Policy.

Print Name_________________________________________________ 		

Patient Signature____________________________________________ 		Date____________________
       (Signature of Parent/Guardian if patient is a minor)

4632 Sawmill Road
Columbus, OH 43220
(614) 545-2002

Patient Name:_________________________________________________________                                 	Date:______________________	

Other than the services we may already provide for you, what additional services
would you like to learn about?  Please check all that apply.

q	Skin care advice
q	Skin care products
q	Facial fine lines/wrinkles
q	Acne
q	Uneven skin tone/texture
q	Brown spots/age spots
q	Facial veins/redness/rosacea
q	Facial fullness/drooping
q	Thin lips/lip lines
q	Drooping eyelids/brow
q	Unwanted body fat
q	Excess chin fat
q	Unwanted hair
q	Thinning hair
q	Spider/varicose veins 
q	Weight Loss

q	Botox® Cosmetic
q	Dysport®
q	Daxxify
q	Dermal Fillers
q	Bellafill®
q	Sculptra® Aesthetic
q	Restylane® 
q	Juvederm®
q	Kybella®
q	Asclera®
q	RHA Collection Fillers
q	Chemical Peels
q	Latisse
q	Obagi

q	CoolSculpt Elite®
q	Skin Rejuvenation 2.0/IPL
q	Fraxel Dual®
q	Virtue RF
q	Subnovii / Plasma Pen
q	Diamond Glow/hydrafacial
q	Microneedling/Vampire Facial
q	Microdermabrasion
q	Dermaplane
q	Waxing/tinting
q	Laser hair reduction
q	PRP
q	Prx-T33
q	Avi-Clear Acne Laser	

Please answer the following questions on a scale of 1 to 5 by circling the appropriate number.
When looking at my face in the mirror, I believe I look younger, the same as, or older than my true age.
Younger Than	
	
True Age	
	
Older Than	

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2	
3	
4	
5	

When looking in the mirror, I am not concerned, somewhat concerned, or very concerned about my appearance.
Not Concerned	
	
Somewhat Concerned	
	
Very Concerned	

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2	
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4	
5