Patient Information Form

PATIENT INFORMATION

























Spouse/Significant Other:



EMERGENCY CONTACT










HISTORY













Have you ever been diagnosed with, or treated for, any of the following conditions?











PREGNANCY



WE REQUIRE A NEGATIVE PREGNANCY TEST BEFORE PROCEDURES OR INJECTIONS - A PREGNANCY TEST WILL BE PROVIDED FOR FREE CHARGE.

SPECIAL RISKS

I understand that tobacco smoke has been shown to impair wound healing, and in some cases leads to scarring. Dr. Holdredge recommends being free of tobacco smoke for 4 months for optimal results with surgery and laser treatments.

Vaping, while generally believed to be safer than cigarettes, has not been adequately studied. Until more information is available, we recommend staying "vape free" as well.



ALLERGIES & SURGERY HISTORY








What is your current skin care regimen?


BEARWOOD, LLC – FINANCIAL POLICY

We accept cash,credit cards,debit cards, and CareCredit. We do not accept personal checks.

A 10% deposit is required to secure time on the schedule for you procedure, with the remainder due in full at the time of service. Full refund of your deposit is assured by giving 48 hours advanced notice of your cancellation.

Contact

309 E. Greenville St., Suite A • Anderson, SC  29621