Patient Name
Name you prefer to be called
Address
Date of Birth
Sex
Age
Home Phone Number
Cell Phone Number
Work Phone Number
Ext
I prefer to be contacted at my home / cell / work phone number (please indicate).
E-mail address
Name and address of your Primary Care Physician
If the patient is a minor, name and address of parent or guardian
How WERE YOU REFERRED TO SEACOAST REJUVENATION CENTER?
Yellow pages *
Newspaper *
Friend or relative *
web site - www.seacoastrejuvenation.com *
Other web site *
TV
Physician *
Mailing or newsletter *
Other *
Please specify *
CONSENT TO BE PHOTOGRAPHED I consent to be photographed before, during and after my treatment. I understand that these photographs shall be the property of Seacoast Rejuvenation Center as a part of my permanent patient record.
Signature of Patient, Parent or Guardian
CONSENT TO USE PHOTOGRAPHS I understand and agree that my photographs may be used for scientific purposes, for internal patient education, publication, and presentations. I understand my identity will be protected.
CONFIDENTIALITY AGREEMENT I understand my records and photographs are strictly confidential. The contents of my records cannot be released to any person or organization without my prior written approval, excluding peer review.