New to NicholsMD

Fill out our new patient paperwork below!

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New Patient Paperwork

Today's Date

Full Name

How May We Address You? (i.e nickname)

Age

Date-of-birth

Gender

Mailing Address

City

State

Zip

Home Phone

Cell Phone

Occupation

Employer

Emergency Contact

Emergency Contact Full Name

Emergency Contact Phone

Emergency Contact Relationship

Pharmacy

Name

City/State

Phone Number

Parent/Responsible Party (if different from Patient)

Full Name

Relationship to Patient

Home Phone

Cell Phone

Email Address

Whom Do We Have the Pleasure of Thanking for Refering You? (Person)

Family/FriendNicholsMD Staff SkinCeuticals

List Name(s) of Referral Person

Whom Do We Have the Pleasure of Thanking for Refering You? (Magazine)

NewBeautyGreenwich Magazine Other

Whom Do We Have the Pleasure of Thanking for Refering You? (Online)Please check all that apply:

InstagramFacebookTwitterLinkedInGoogleYelpYouTubeHealthgrades

Other Referral (Please Explain)

Another Physician's Office? (Name of Physician)

MEDICAL HISTORY

Do You Have Any Allergies To Medication?pick one!

YesNo

If Yes, Please List The Names Of The Medications You Are Allergic To:

Please List Any Medical Conditions You Have:

Please List Any Medications You Currently Use:(Include Over-The-Counter And Topical Medications, Vitamins And Herbal Supplements)

Do You Have A History Of Skin Cancer Or Another Severe Skin Condition?pick one!

YesNo

If So, Please Describe:

Do Any Close Family Members Have A History Of Skin Cancer Or A Severe Skin Disease?pick one!

YesNo

If So, Please Describe:

Do Any Close Family Members Have A History Of Skin Cancer Or A Severe Skin Disease?

pick one!

Email or PhoneEmail OnlyPhone Only

Do Any Close Family Members Have A History Of Skin Cancer Or A Severe Skin Disease?

An annual full-body skin examination to screen for skin cancer is recommended. There is no additional charge for this exam over the initial office visit charge. The exam is performed with a gown and undergarments on. Would you like this exam performed?pick one!

YesNo

COSMETIC QUESTIONNAIRE

SkinCeuticals SkinLab has a curated menu for selective luxury services in under an hour. Below is our full menu of services, available at NicholsMD of Greenwich. For our entire Before and After Gallery.

Specific Areas of Concern

AcneAcne ScarringAged HandsBroken CapillariesBrown SpotsCelluliteChest Sun Damage/WrinklesCrow’s FeetCyst InjectionDark Under-Eye CirclesDouble ChinDropping/Sunken CheeksEarlobe SaggingExcessive SweatingFacial RednessForehead LinesHair LossIncontinenceJowlsLarge PoresLeg Veins / Spider VeinsLoose Sagging SkinLow Energy LevelsMelasmaNose CorrectionNeck sun damage/wrinklesSmile Lines/Frown Lines ScarringStretchmarksStubborn Fat Stubborn Fat Sunken EyesThin Lips/Lip Lines Thinning Lashes Uneven Skin Tone Unwanted Body Hair Unwanted Facial HairUnwanted MolesUnwanted Skin TagsOther

If Other Specific Areas of Concern

Notable Procedures of Interest

AquaGoldBotoxB12 InjectionsChemical PeelsCO2 Laser ResurfacingCoolsculptingDermaplaningDyportEmSculptExcel V Global RevitalizationFacialsFeminine Rejuvenation FillersFraxelJeuveauJuvedermKybellaLaser GenesisLaser Hair RemovalLED Light TherapyMicrodermabrasionMicroneedlingPRP for Hair GrowthSclerotherapySculptraSilhouette InstaliftSkinscopeUltherapyVitamin IV TherapyVolumaXeominOther

If Other Specific Areas of Concern

NOTICE OF PRIVACY PRACTICES CONSENT

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Patient Understands That:

Protected health information may be disclosed or used for treatment, payment, or health care operations

The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice

The Practice reserves the right to change the Notice of Privacy Practices

The Patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions

The Patient may revoke this Consent in writing at any time and all future disclosures will then cease

The Patient may condition receipt of treatment upon the execution of this

Authorization, Assignment And Acknowledgment

My signature below indicates that I have read and understand this consent in its entirety, that my questions have been adequately answered, and that a copy of the Notice of Privacy Practices is available to me upon my request.

Please Check for Authorization

Authorized

Today's Dateof appointment

PHOTOGRAPHY RELEASE FORM

I understand that taking medical photographs is an important part of patient care. Thus, I authorize NicholsMD of Greenwich, Dr. Kim Nichols and staff representatives, to take photographs of my body for medical purposes. These photographs will ONLY be used for my patient care.

Please Check for Photography Release

Authorized

Today's Dateof appointment

FINANCIAL POLICY AT NICHOLSMD

Financial Policy

Payment is due in full at the time of service for consultations, examinations, and procedures. We accept cash, checks, and all major credit cards. As a courtesy, we also offer Care Credit™, a credit card financing program for cosmetic procedures. Please ask for more information if you are interested.

Our office will keep your credit card on file in order to expedite checkout transactions, charge non-refundable deposits towards specific appointments, and/or cancellation etiquette breaches.

All consultation fees, follow-up appointment fees, deposits, and procedures done at SkinLab are considered services rendered, and thus, are non-refundable.

Cancellation Etiquette

SkinCeuticals SkinLab has a 24-hour cancellation policy. All appointments canceled less than 24 hours prior to the appointment will be charged $175, We also require non-refundable deposits for specific treatments and Saturday appointments.

My signature below indicates that I am fully aware of the financial and cancellation policies of SkinCeuticals SkinLab, and I accept full responsibility for all expenses incurred. In addition, I grant authorization to release any information required to obtain payment of medical benefits.

I have read and understand this statement in its entirety and my questions have been adequately answered.

Authorization, Assignment and Acknowledgment

By signing this document you have been made aware and agree to our financial and cancellation policies.

Please Check for Financial Authorization

Authorized

Today's Dateof appointment

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My mother and I are moving to Chicago and I am going to miss Dr. Nichols and her staff. What a lovely bunch. They are truly genuine, paying attention with detail to your skin needs. Did I mention they go way beyond to ensure you have everything you need to take care of your skin. Our skin feels and looks AMAZING. You definitely will not regret investing into Dr. Nichols.

Genese Leach

15:41 31 Mar 18

The entire staff is friendly, professional and knowledgeable. Very happy with Katie’s treatments. She listened to my “wants” and delivered, making treatment easy and pain-free! Also, Jessica gives great facials and knows how to pamper you! The office is amazing, sleek and modern and their products have changed my skin for the best! Love NicholsMD

Stephany Chavez

22:02 25 Feb 18

NicholsMD was the best skincare experience I ever received. From the beautiful office to the warm, smiling faces when you enter, I knew at once I was at home. Katie French, PA-C, was everything you would want in a medical professional. She listened to my concerns and needs and then walked me through the entire process. She only recommended what was necessary and had a degree of professionalism of someone who has thirty years of experience. Katie took the time to answer all my questions and I’ve never walked away wih smoother and clearer skin. She was warm, friendly, and incredibly skilled with the procedure. I’ve loved every visit to NicholsMD. I will be a lifetime patient of Katie French, PA-C, Dr. Nichols, and the rest of their staff. Make an appointment, you will never be happier!

Kristen Kelsay

14:21 09 Mar 18

Excellent providers, excellent service, incomparable amenities. Amazing patient care, staff truly goes above and beyond for patients. The office is incredibly pristine and gorgeous to boot! As a physician myself, I could not recommend more highly NicholsMD for your dermatologic needs.

Natalie Yin

14:30 16 Apr 18

There is no place like NicholsMD! From the gorgeous office to the services and staff, NicholsMD of Greenwich is truly one of a kind. I got the results I wanted in 3 treatments and could not be happier! Highly recommend.