Medical consultation with Dr. Chao – skin & hair disorders

    Instagram: @dannychaomd

    Patient Information:

    1. I am aware that my appointment is with Dr. Chao who is a family physician with a special interest in skin and hair disorders who also practices medical aesthetics/cosmetics.


    *In order to properly manage your care, we kindly ask you to limit the reason of your visit today to the reason outlined by your referring doctor. Additional visits or referrals may be deemed necessary upon discussion with Dr. Chao.

    ItchyBurningPainSwellingTendernessDrainingBleedingNone

    NOYES

    3. Do you have a history of the following?

    Local anesthetic sensitivityIV drug useKeloidsCold soresAnticoagulant medicationsHepatitis B/C or positive HIVBleeding disordersStomach ulcersPacemaker or defibrillatorEpilepsyDiabetesHigh blood pressureSmokingVasovagal tendency

    4. For females:

    Are your periods regular?Are you using birth control?Are you pregnant or breastfeeding?Do you plan to become pregnant in the next 2 years?

    5. Have you had any surgeries?

    NOYES

    6. Do you take any medications regularly including prescriptions, over-the-counter and herbal supplements

    NOYES

    7. Do you have any allergies to medications?

    NOYES

    8. Have you had any history of skin cancer?

    NOYES

    9. Have any family members had any history of skin cancer?

    NOYES

    10. If your referral is about hair loss, have any family members had any history of hair loss?

    NOYES

    11. Dr. Chao strives to provide comprehensive skin care to our patients. In addition to medical services, Dr.Chao also offers various cosmetic solutions to enhance your appearance, well-being and to restore your natural beauty. Your satisfaction and comfort are important to us. Please check any of the concerns or cosmetic services below that you may be interested in finding out more about:

    Fine lines and wrinklesAcne scarsRadiofrequency MicroneedlingSurgical scarsAge or dark spotsStretch marksSkin texture/large poresHair thinningDry or crepey skinDull complexionBotox/Dysport injectablesCollagenExcessive sweatingUndereye bagsOther

    What is your level of interest in addressing any of these concerns or cosmetic services?

    Very interestedSomewhat interestedNot interested

    If you are interested in learning about anti-aging solutions and to restore and enhance your natural beauty with natural-looking results, follow @dannychaomd on Instagram to stay informed about upcoming promotions, special offers and events for cosmetics and medical aesthetics.

    No-Show Policy:

    We understand that unforeseen circumstances may arise, causing patients to miss their scheduled appointments. However, missed appointments disrupt our ability to provide timely care to all of our patients. To ensure the efficient operation of our practice and to better serve all patients, Dr. Chao's office has implemented the following no-show policy:

    Appointment Confirmation:
    • Patients are responsible for scheduling and confirming their appointments.

    Late arrivals:
    • Patients are expected to arrive on time for their appointments. Arriving late may result in the need to reschedule the appointment, depending on the availability of our healthcare providers.

    • We try our best to see you at your scheduled appointment time but please be aware that unforeseen circumstances or medical emergencies may arise which may delay when the doctor can see you. We appreciate your understanding and thank you for your patience.

    No-show fee:
    • A fee of $125.00 will be charged to patients for each missed appointment without prior notification.

    • This fee is not covered by insurance and is the responsibility of the patient. It must be paid before scheduling any future appointments.

    Cancellation policy:
    • Patients are encouraged to provide at least 24 hours advance notice if they need to cancel or reschedule their appointment.

    • Cancellations made within 24 hours of the scheduled appointment may also be subject to the no-show fee, depending on the circumstances.

    Repeat no-shows:
    • Patients who repeatedly miss appointments or fail to comply with the no-show policy may be subject to further action, including dismissal from the practice.

    By scheduling an appointment at Dr. Chao's office, patients acknowledge that they have read, understood, and agreed to comply with the no-show policy outlined above.

    Thank you for your cooperation in helping us maintain efficient and effective healthcare services for all of our patients.

    *If a medication is prescribed to you during your visit, the prescription paper will be printed off at the reception desk for you to pick up before you leave. It is your responsibility to pick up your prescription paper from the reception desk before you leave the office.*

    Date*:

    Patient Signature*: