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:

"*" indicates required fields

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:*

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

Do you have a history of cold sores?*

Yes

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

Do you smoke?*

Yes

Do you consume alcohol?*

Yes

Do you visit a tanning salon?*

Yes

Do you exercise?*

Yes

Do you follow a restricted diet?*

Yes

Do you wear contact lenses?*

Yes

Do you have metal implants, a pacemaker or body piercings?*

Yes

Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks?*

Yes

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

Do you burn easily in moderate sunlight?*

Yes

Do you have a tendency to redness?*

Yes

Do you ever experience burning, itching or stinging sensations on your skin?*

Yes

Have you ever used any of the following? Check all that apply:*

Have you ever had any of these procedures? Check all that apply:*

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:*

For your body? Check all that apply:*

Are you currently using any products that contain the following ingredients? Check all that apply:

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

Does your contraception include hormones or do you use hormone replacement therapy of any kind?*

Yes

Are you currently having or due for your menstrual period?*

Yes

For Male Clients

Do you have any shaving challenges?*

Yes

Specify your shaving challenges*

Please sign and date the form:

Signature*

Date*

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

Signature*

Date*

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

Do you have a family member (blood relative) with glaucoma?*

Yes

Do you have a history of elevated intraocular pressure?*

Yes

Are you currently taking medication for eye pressure problems?*

Yes

Are you pregnant or breast feeding?*

Yes

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*

Nu-Derm Program Consent

Signature*

Date*

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

Signature*

Date*

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

Signature*

Date*

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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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