New Patient Registration Title * Mr Mrs Ms Miss Dr Name * First Name Last Name Gender Male Female Other Date of Birth * MM DD YYYY Nationality * Address (Area) * Home Phone Country (###) ### #### Work Phone Country (###) ### #### Mobile * Country (###) ### #### WhatsApp If different from Mobile No. Country (###) ### #### Email * How would you prefer us to contact you? * Call SMS WhatsApp Email Do you consent to SMS/WhatsApp for reminders? * Yes No How did you hear about us? * Referral Instagram Website Google Other Reason for visit * Medical Information Have you undergone any surgery to the area of treatment in the last 6 months? * Yes No Are you currently on any medication? * Please include herbal medication e.g. fish oil, aspirin) Yes No If yes, please state: Do you have any allergies? * E.g. Nuts, Latex etc Yes No Have you had any aesthetic treatments in the past? Yes No If yes, please state: Are you pregnant or trying to conceive? Yes No Are you breastfeeding? Please ignore if not applicable Yes No Do you smoke? Yes No Do you have a history of Keloid Scars? Yes No Do you suffer from Cold Sores? Yes No Are you currently undergoing any treatment? Yes No If yes, please state: Do you have Diabetes? Yes No Do you have Eczema/Dermatitis/Psoriasis? Yes No Do you have any other medical conditions? Skin Appearance Are you suffering from Active Acne/Oily skin/Rosacea? Yes No Do you experience skin sensitivity/dry or flaky skin? Yes No Do you experience skin laxity? Yes No Do you have any pigmentation issues? Yes No Any other known skin conditions? How much is your sun exposure? < 2 hours 2-4 hours > 4 hours Home Care Do you use a cleanser? Yes No Do you use a moisturiser? Yes No Do you use a Retinol or Vitamin A? Yes No Do you use a toner? Yes No Do you use an eye cream or serum? Yes No Do you use SPF/sunscreen? Yes No Do you use any other products? Interests Fillers or Botox Acne or Acne Scar Treatments Dermatology Concerns Medical Facial Skin Rejuvenation Pigmentation Treatment Mole Check Skin Tightening Patient Consent Declaration By clicking submit, I, authorise ATHENA DERMATOLOGY CLINIC to carry out medical examination, investigation, medical treatment, and diagnostic procedures during the course of my care be deemed advisable or necessary with no guarantees about the final results the treatment. I consent to pay all charges of the services that will be rendered to me according to the clinic's regular price list. I confirm that I am the patient (or the Patient's parent or guardian if the patient is under 18 years of age), hereby consent to and authorise the medical provider, agents, health professional or other relevant administrative establishment to provide and discuss with me and/or any of my family members about any health/treatment/billing details, medical records or discharge arrangements (past or present) with and to the insure and/or Third Party Administrator. I agree that a copy of this consent shall have the validity of the original. I agree that healthcare provider(s) involved in my care at this facility will access my health information through the Health Information Exchange System (NABIDH) in accordance with the Laws of the United Arab Emirates, Emirate of Dubai Legislation and Dubai Arab Emirates, Emirate of Dubai Legislation and Dubai Health Authority Policies. I agree to deal with all medical education workforce including trainees, students, and volunteers, as long as it is under direct supervision of the treating healthcare practitioners including their presence for observation during consultation, treatment. I have received a copy of Patient & Family Rights and Responsibilities and explained by the hospital staff. Thank you!
