• Minor 
• Single 
• Married 
• Separated 
• Divorced 
• Widowed 
• Partnered  for  years.

Patient Employer / School Occupation Employer / School Address Employer / School Phone Whom may we thank for referring you? In case of emergency, who she be notified? Phone

Relation to Patient

Birthdate Social Security #

Address City State ZIP

Employed By Occupation

Business Address Business Phone

Insurance Company

Contract Number Group Number Subscriber Number

Is patient covered by other insurance?  Yes

Relation to Patient

Birthdate

Please print name of Patient, Parent, Gaurdian or Person Responsible Relationship to Patient

Address

Employed By Business Phone

Insurance Company

Contract Number Group Number Subscriber Number

I certify that I, and / or my dependent(s) have insurance coverage with and authorize payment directly.

Signature of Patient, Parent, Guardian or Person Responsible Date

Past Medical History: (Please check all that apply)

Past Surgical History (Please check all that apply)

Skin Disease History (Please check all that apply)

• Acne 
• Actinic Keratoses 
• Asthma 
• Basal Cell Skin Cancer 
• Blistering Sunburns 
• Dry Skin 
• Eczema 
• Flaking or Itching Scalp 
• Hay Fever / Allergies 
• Melanoma 
• Poison Ivy 
• Precancerous Moles 
• Psoriasis 
• Squamous Cell Skin 
• Cancer 
• None 
• Other:

Do you wear Sunscreen?  Yes  No  If yes, what SPF? 

Do you tan in a tanning salon?  Yes  No 

Do you have a family history of Melanoma?  Yes  No  If yes, which relative(s)? 

Medications: (Please enter all current medications)

Allergies: (Please enter all current allergies)

Social History: (Please check all that apply)

Currently Smokes: Daily  Currently Smokes: Not Daily  Has Smoked in the past  Has never smoked  None  Other: Referred By: Primary Care Physician:

I hereby authorize payment directly to for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf of my dependents.

I authorize the above doctor and / or any provider or supplier of services in the office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Signature of Responsibility Party: Date:

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California low provides forjudicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of low before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician's partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common low.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:

If any provision of this arbitration agreement is held invalid or unenforeable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any of the provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have recevied a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE ARBITRATED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL SEE ARTICLE 1 OF THIS CONTRACT.
Effective as of the date of first medical services.

Patient / Parent / Guardian (Please Print): Date: Patient / Parent / Guardian Signature: Print Name of Physician, Medical Group or Association Name:

1. This notice is effective 01-01-2017
   I have read the Privacy Notice (HIPPA), and understaood my rights contained in the noticed.
   Again, if you have any questions regarding this notice or our Health Information Privacy Policies, please contact the Privacy Officer at:
   Mission Hills 15336 Devonshire #1, Mission Hills, CA 91345 - Tel: (818)&nbps;894-5616 - Fax: (818) 893-4872
   Palmdale 41230 11th Street West, Suite #E, Palmdale, CA 93551 - Tel: (661) 224-1449 - Fax: (818) 893-4872
2. I understand that all procedures that not cancelled 24 hours prior to the appointment time are subject to a $35.00 cancellation charge.
3. Be advised that Dr. Frank Lusher, M.D. is the acting Medical Director of this practice and all insurance billing will be done through him in accordance with ICD-10 rules and regulations. There are multiple providers in this practice and you may be seen by either, Chris Towery, PhD, NP, Alejandra Martinez, MS, PA-C, Kristine Nguyen, MSPAS, MPH, PA-C or Bernard Marcos, MD.
4. Daycare is not provided in the office and for the safety of your children please do not bring you child to any appointment if they are not being seen. Bringing your child without childcare may result in having to reschedule your appointment and you may be subject to the cancelation fee.
5. Please note that there will be no refund or substitution for any Treatment Package purchased and all cosmetic procedure results are not guaranteed.
6. I also understand that I have the right to ask for additional information on the procedures that I am receiving prior to treatment.

I HAVE READ AND UNDERSTOOD THE ABOVE ACKNOWLEDGEMENTS:

Patient / Parent / Guardian (Please Print): Patient / Parent / Guardian Signature: Date: