Rx Prescription Form

To help us expedite your order, please complete the forms which are required in order to fill online orders for prescription-strength products. After you click Submit, check your email for a confirmation that your forms were received. Click on the first box below to begin:

Online orders for prescription-strength products

Prescription products are subject to doctor approval and require an online consultation with a physician after checkout who will determine if a prescription is appropriate.
Patient's Name*
First Last
Email*
Phone*
Alternate Phone
Home Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Occupation*
Sex*
HIPPA Patient Form

Notice of Privacy Practices
The following is a required "notice of privacy practices" (NPP) in keeping with Federal and State HIPAA requirements. -Overview of Privacy Issues: The laws regarding privacy of personal health information are complicated. Federal regulations require your approval of a full NPP as part of receiving health services. To accomplish this, I will provide you with a copy of the full, legally required NPP and this shorter version, which summarizes the same information. Finally, there is a standard consent form that documents your agreement with the NPP. I am not permitted to provide treatment without an executed consent form. You also may have additional questions or concerns, including about situations not covered by this information, and you are encouraged to voice these. The health information in your records will be mainly used to provide treatment, to arrange payment for services, and for some other business activities that are called, in the law, "health care operations." Before private information can be disclosed (sent, shared, or re1eased) for any additional purposes, a separate authorization form is required to allow it.
Your health information is private and will be kept that way
There are some times when the law requires disclosure. For example: 1. When there is a serious threat to your health or safety or the health or safety of another individual or the public. Information would then be shared with a person or organization that is able to help prevent or reduce the threat. 2. Some lawsuits and legal or court proceedings. 3. If a law enforcement official requires us to do so. 4. For Workers Compensation and similar benefit programs. 5. There are other situations like these but which happen very rarely.
Your rights regarding your health information:
1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place for more privacy. For example, you could ask me to call you at home and not at work to schedule or cancel an appointment. I will try my best to do as you ask. 2. You can request that I limit what is disclosed to any people who are involved in your treatment or the payment for treatment, such as family members or friends. If I agree to the request, I would attempt to keep that agreement except if it is against the law, or in an emergency, or when the information is necessary to treat you. 3. You have the right to look at your health information, such as billing records or health records associated with your skin care. You can even get a copy of these, provided that you reimburse your provider for time and copy expenses involved. 4. If you believe that any information in your records is incorrect or missing important information, you can ask to have some kinds of changes (termed "amending") to your health information. You would have to make such a request in writing and send it to the office, and you would also need to write the reasons that you want to make the changes. 5. You have the right to a copy of this notice and to the longer NPP. 6. You have the right to file a complaint if you believe that your privacy rights have been violated.
The effective date of this notice is:*
MM slash DD slash YYYY
Consent*
I have read and understand the above Notice.
Good Faith Exam

Note: this is a confidential record of your medical history. Information collected here is for the sole use of Skin Deep. Information collected here will not be released to any person without your written authorization.
Your Health
Within the last year, have you been under a dermatologist’s or other physician’s care?*
- Yes
- No
Do you have a history of cold sores?*
- Yes
- No
Please list your current medications, or state "none"*
Tell us about any allergies that you have, or state "none"*
Have you started any new medications since the last time you filled out this form?*
- Yes
- No
Do you smoke?*
- Yes
- No
Do you consume alcohol?*
- Yes
- No
Do you visit a tanning salon?*
- Yes
- No
Do you exercise?*
- Yes
- No
Do you follow a restricted diet?*
- Yes
- No
Do you wear contact lenses?*
- Yes
- No
Do you have metal implants, a pacemaker or body piercings?*
- Yes
- No
Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks?*
- Yes
- No
Rate your level of stress on a scale of 1 to 5 (1 = low stress, 5 = high stress)*
Please enter a number from 1 to 5.
Your Skin
Do you use SPF (sunscreen)?*
- Yes
- No
Do you burn easily in moderate sunlight?*
- Yes
- No
Do you have a tendency to redness?*
- Yes
- No
Do you ever experience burning, itching or stinging sensations on your skin?*
- Yes
- No
Have you ever used any of the following? Check all that apply:*
- Retin A
- Hydroquinone
- Accutane
- Zovirax
- Valtrex
- None of these
Have you ever had any of these procedures? Check all that apply:*
- chemical peel
- waxing
- electrolysis
- facial surgery
- None of these
Describe your specific concerns/challenges with your skin, or state "none":*
Which of these do you currently use for your face? Check all that apply:*
- soap
- cleanser
- toner
- moisturizer
- masque
- exfoliator
- eye products
- none of these
For your body? Check all that apply:*
- soap
- shower gel
- scrubs
- oil
- moisturizer
- depilatory products
- self-tanners
- none of these
Are you currently using any products that contain the following ingredients? Check all that apply:
- glycolic acid
- lactic acid
- any exfoliating scrubs
- any hydroxyl acid products
- Vitamin A derivatives (i.e., Retinol)
- none of these
Do you ever experience these conditions on your skin?*
- flakiness
- tightness
- obvious dryness
- none of these
For Female Clients
Are you pregnant or lactating?*
- Yes
- No
Does your contraception include hormones or do you use hormone replacement therapy of any kind?*
- Yes
- No
Are you currently having or due for your menstrual period?*
- Yes
- No
For Male Clients
Do you have any shaving challenges?*
- Yes
- No
Specify your shaving challenges*
Please sign and date the form:
Signature*
Date*
MM slash DD slash YYYY
Prescription Products

Please indicate what products you are interested in purchasing from Skin Deep today or within one year - Check all that apply*
- Obagi Tretinoin Cream or Gel (any strength), or Refissa (any size)
- Latisse
- Obagi Nu-Derm Blender , Nu-Derm Clear, or Nu-Derm Transformation Kit (any size)
- Skin Deep Skin Tone Enhancement System
- Obagi-C Rx C-Clarifying Serum
Obagi Tretinoin (0.25%, .05%., 1%) & ReFissa (.05%) Consent
Consent*
Tretinoin must be used in the prescribed fashion according to the written instructions and descriptions given to me. I understand that I will experience varying degrees of the following symptoms: Dryness - Redness - Exfoliation/Peeling - Itching - Sensitive Skin - Burning - Wrinkles May Look Worse - Acne May Look Worse. These symptoms will lessen and eventually subside as my skin builds tolerance.
Consent*
I agree to continue with the use of Tretinoin and to return for follow-ups as directed. Doing so will help with my safety and provide adjustments towards maximizing results.
Consent*
I understand the best results are achieved with adherence to the program over several weeks and/or months.
Consent*
I understand that excessive application of the products or picking, rubbing the skin can cause a great deal of discomfort and even blistering, especially in the early weeks of treatment. If any reactions are initiated to the point of skin breakdown or infection, I will contact the office immediately. Careless inattention to such reactions may result in complications such as infection, injury, discoloration, or possible superficial scarring.
Consent*
I understand that it is necessary to maintain the use of my prescribed protocol throughout the treatment period. This is necessary to retain the benefits during the program.
Consent*
If you are pregnant, think you are pregnant, or are nursing an infant. No studies have been conducted in humans to establish the safety of Tretinoin in pregnant women. If you are pregnant, think you’re pregnant, or are nursing a baby, consult your physician before using the medication. It is not recommended that you use Tretinoin if you are pregnant, think you are pregnant, or are nursing an infant.
Consent*
I understand a sunscreen of at least SPF 50 is to be used on a daily basis, and to practice sun safe guidelines when outdoors.
Consent*
I understand that I must adhere to the guidelines prescribed.
Consent*
I have read and fully understand the above, received satisfactory answers to my questions, and had a chance to discuss alternative treatments.
Signature*
Date*
MM slash DD slash YYYY
Latisse Consent
Latisse is a prescription treatment approved by the FDA
Latisse is a prescription treatment approved by the FDA to grow longer, thicker, and darker eyelashes. - Latisse is believed to affect the growth phase of the eyelash hair cycle in 2 ways; first, it increases the length of the “growth” phase; and second, it increases the number of hairs in the “growth” phase. The exact way in which Latisse works is still unknown. - The onset of results is gradual but usually a significant improvement. Latisse is believed to affect the growth phase of the eyelash hair cycle in 2 ways; first, it increases the length of the “growth” phase; and second, it increases the number of hairs in the “growth” phase. The exact way in which Latisse works is still unknown.
Do you have a personal history of Glaucoma?*
- Yes
- No
Do you have a family member (blood relative) with glaucoma?*
- Yes
- No
Do you have a history of elevated intraocular pressure?*
- Yes
- No
Are you currently taking medication for eye pressure problems?*
- Yes
- No
Are you pregnant or breast feeding?*
- Yes
- No
Possible side effects
Possible side effects (reported by approximately 4% of users in the Latisse clinical trial) would include: - Eye itching - Eye redness Other less common side effects occur on the skin close to where Latisse is applied, or in the eyes: - Eye irritation - Dryness or redness of the eyelids - Darkening of eyelid skin which may be reversible - Darkening of the eye color, for instance, hazel, green or blue eyes change to brown (likely to be permanent) this was not seen in the clinical trials for Latisse, however has been documented when the product is used as an eye drop for glaucoma. - Unwanted hair growth in an adjacent area (This did not appear to be a permanent effect) - If you develop a new eye condition (like an eye trauma or infection), experience a sudden decrease in vision, have eye or eyelid surgery, or develop any eye or eyelid reactions, particularly an infection, or if you become pregnant, you should immediately talk to your doctor about whether or not to continue using Latisse solution.
Signature*
Date*
MM slash DD slash YYYY
Nu-Derm Program Consent
Consent*
I understand that the creams must be used in the prescribed fashion according to the written instructions and descriptions given to me.
Consent*
I understand that I will experience varying degrees of the following symptoms: Dryness - Redness - Exfoliation/Peeling - Itching - Sensitive Skin - Burning - Wrinkles May Look Worse - Acne May Look Worse. These symptoms will lessen and eventually subside as my skin builds tolerance.
Consent*
I agree to continue with the use of the Nu-Derm products and to return for follow-ups as directed. Doing so will help with my safety and provide adjustments towards maximizing results.
Consent*
I understand the best results are achieved with adherence to the program over several weeks and/or months.
Consent*
I understand that excessive application of the products or picking, rubbing the skin can cause a great deal of discomfort and even blistering, especially in the early weeks of treatment. If any reactions are initiated to the point of skin breakdown or infection, I will contact the office immediately. Careless inattention to such reactions may result in complications such as infection, injury, discoloration, or possible superficial scarring.
Consent*
I understand that it is necessary to maintain the use of my prescribed Nu-Derm protocol throughout the treatment period and also during the maintenance period. This is necessary to retain the benefits during the program.
Consent*
I understand that no guarantee or assurance has been given to me as to the results that may be obtained.
Consent*
I understand that a sunscreen of at least SPF 50 is to be used on a daily basis and to practice sun safe guidelines when outdoors.
Consent*
I have been advised that Hydroquinone products are to be used for a course of no more than four months at a time. Products such as Discoloration Defense, Pigment Correcting Brightener, Brightening Pads, or other non-Hydroquinone brightening products can be used to help with discoloration concerns while off of Hydroquinone.
Consent*
I understand that I must adhere to the guidelines prescribed.
Consent*
I have read and fully understand the above, received satisfactory answers to my questions, and had a chance to discuss alternative treatments.
Signature*
Date*
MM slash DD slash YYYY
Skin Deep Skin Tone Enhancement System (with Hydroquinone 4%) Consent
Consent*
The pads must be used in the prescribed fashion according to the written instructions and descriptions given to me. I understand that I may experience varying degrees of the following symptoms:
Dryness - Redness - Exfoliation/Peeling - Itching - Sensitive Skin - Burning - Wrinkles May Look Worse - Acne May Look Worse. These symptoms will lessen and eventually subside as my skin builds tolerance.
Consent*
I agree to continue with the use of the Skin Deep Skin Tone Enhancement System as directed. Doing so will help with my safety and provide adjustments towards maximizing results.
Consent*
I understand the best results are achieved with adherence to the program over several weeks and/or months.
Consent*
I understand that excessive application of the products or picking, rubbing the skin can cause a great deal of discomfort and even blistering, especially in the early weeks of treatment. If any reactions are initiated to the point of skin breakdown or infection, I will contact the office immediately. Careless inattention to such reactions may result in complications such as infection, injury, discoloration, or possible superficial scarring.
Consent*
I understand that it is necessary to maintain the use of my prescribed Skin Deep Skin Tone Enhancement System protocol throughout the treatment period and also during the maintenance period. This is necessary to retain the benefits during the program.
Consent*
I understand that products with hydroquinone should not be used when pregnant or lactating.
Consent*
I understand a sunscreen of at least SPF 50 is to be used on a daily basis and to practice sun safe guidelines when outdoors.
Consent*
I have been advised that Hydroquinone products are to be used for a course of no more than four months at a time. Products such as Discoloration Defense, Pigment Correcting Brightener, Brightening Pads, or other non-Hydroquinone brightening products can be used to help with discoloration concerns while off of Hydroquinone.
Consent*
I understand that I must adhere to the guidelines prescribed.
Consent*
I have read and fully understand the above, received satisfactory answers to my questions, and had a chance to discuss alternative treatments.
Signature*
Date*
MM slash DD slash YYYY
Obagi-C Rx C-Clarifying Serum (with 4% Hydroquinone) Consent
Consent*
Obagi-C Rx C-Clarifying Serum must be used in the prescribed fashion according to the written instructions and descriptions given to me. I understand that I may experience varying degrees of the following symptoms:
Dryness - Redness - Exfoliation/Peeling - Itching - Sensitive Skin - Burning - Wrinkles May Look Worse - Acne May Look Worse. These symptoms will lessen and eventually subside as my skin builds tolerance.
Consent*
I agree to continue with the use of Obagi-C Rx Serum as directed. Doing so will help with my safety and provide adjustments towards maximizing results.
Consent*
I understand the best results are achieved with adherence to the program over several weeks and/or months.
Consent*
I understand that excessive application of the products or picking, rubbing the skin can cause a great deal of discomfort and even blistering, especially in the early weeks of treatment. If any reactions are initiated to the point of skin breakdown or infection, I will contact the office immediately. Careless inattention to such reactions may result in complications such as infection, injury, discoloration, or possible superficial scarring.
Consent*
I understand that it is necessary to maintain the use of my prescribed Obagi-C Rx C-Clarifying Serum protocol throughout the treatment period and also during the maintenance period. This is necessary to retain the benefits during the program.
Consent*
I understand that products with hydroquinone should not be used when pregnant or lactating.
Consent*
I understand a sunscreen of at least SPF 50 is to be used on a daily basis and to practice sun safe guidelines when outdoors.
Consent*
I have been advised that Hydroquinone products are to be used for a course of no more than four months at a time. Products such as Discoloration Defense, Pigment Correcting Brightener, Brightening Pads, or other non-Hydroquinone brightening products can be used to help with discoloration concerns while off of Hydroquinone.
Consent*
I understand that I must adhere to the guidelines prescribed.
Consent*
I have read and fully understand the above, received satisfactory answers to my questions, and had a chance to discuss alternative treatments.
Signature*
Date*
MM slash DD slash YYYY
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Rx Prescription Form

Online orders for prescription-strength products

HIPPA Patient Form

Good Faith Exam

Your Health

Your Skin

For Female Clients

For Male Clients

Please sign and date the form:

Prescription Products

Obagi Tretinoin (0.25%, .05%., 1%) & ReFissa (.05%) Consent

Latisse Consent

Nu-Derm Program Consent

Skin Deep Skin Tone Enhancement System (with Hydroquinone 4%) Consent

Obagi-C Rx C-Clarifying Serum (with 4% Hydroquinone) Consent

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