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Call Us Today: (503) 928-6505
1706 NW Glisan Street, Suite 2, Portland, OR 97209

NEW PATIENT REGISTRATION

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

General Patient Information

Patient Name :
*Last Name :
Middle Name : *First Name :
*Date of Birth :
Age : Occupation :
*Home Address
City :
State :
Zip :
*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 Yes No
Trying to get pregnant Yes No
History of hypertrophic/keloidal scaring? Yes No
Lupus Yes No
Recent exposure to sun/tanning booths Yes No
Do you freckle in the sun Yes No
Cancer / Melanoma Yes No
Diabetes Yes No
Folliculitis Yes No
Heart Problems Yes No
Date of last period Yes No
Menopausal Symptoms Yes No
Polycystic Ovarian Cancer Yes No
Other metabolic diseases Yes No
Relatives with excessive hair Yes No
Dental Fillings/Metal Pins Yes No
Taken Accutane in the past year Yes No
Allergic to Lidocaine /other anesthetics Yes No
History of Hives Yes No
Do you drink alcohol Yes No
Are you nursing Yes No
HIV/AIDS Yes No
Psoriasis Yes No
Sun rash or photo allergic Yes No
Recent use of sunless tanning cream Yes No
Epilepsy Yes No
Family history of cancer/melanoma Yes No
Herpes/Cold Sore Yes No
Pigmentation Disorder Yes No
Pacemaker Yes No
Irregular Periods Yes No
Total Hysterectomy Yes No
Adrenal Hyperplasia Yes No
Recent increase in hair amount/growth Yes No
High Stress Level Yes No
Cosmetic Tattoos Yes No
Use Retin A or Alpha/Beta Hydroxy Acids Yes No
Allergic to Vitamin B Yes No
St. John’s Wort or Vitamin E use Yes No
Do you smoke Yes No
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? Yes No
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.
Always burn/Never tan Always burn/Sometimes tan Rarely burn/Always tan
American Indian or Hispanic African American
For Laser Hair Removal Patients: What is your current form of hair removal?
Shave Bleach Electrolysis Pluck Wax Depilatory Creams
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. 1 2 3 4 5
I feel that the length and thickness of my eyelashes is not what it once was. 1 2 3 4 5
As I’ve gotten older, I’ve noticed that the color, tone, and texture of my skin has gone downhill. 1 2 3 4 5
As I’ve aged, I’ve become more concerned with the appearance of fine lines and wrinkles around my eyes and forehead. 1 2 3 4 5
Other than the services we are seeing you for today, what additional services Would you like to learn about?
Please check all that apply.
Skin care advice/Products Skin care products Injectable Treatments
Juvederm /Voluma Dermal Filler Radiesse/Belotero/Restylane
Thinning lips Botox Dysport
Drooping Eyelids Facial fine lines/wrinkles Frown lines
PRP Non-surgical eyelid lift Ultherapy
Facial veins Spider Veins Facial redness
Brown spots/age spots/freckle DOT / Fractional laser/Fraxel Scar revision
Facial Plastic Surgery Face / neck lift Acne treatments
Medical weight loss Menopause management Exilis
Cellulite Treatment Cool Sculpting Micro-Needling/Rejuvapen
Fat Reduction Laser Hair Reduction Body Contouring
Vanquish Laser hair removal Latisse
Length / Fullness of eyelashes Tattoo revision Hair regeneration
Testosterone Replacement Therapy Bio-identical hormones Libido enhancement

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.
* I attest that I have answered the above health questions to the best of my knowledge
*Patient / Legal Guardian Signature
Date