INTERESTS 0+*)1('2#3*'%*(%&'#4'+56(*(&6-'&(*7+)(&'2#3',(&+*(-'#*'&+$812',(6%+1'2#3*'+56(*(&6&'9(1#:;'

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1 !"$%&'!"()"%*+,(&-'./!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"$%&'($)*+,$-.&/$ $-/$78&*5/$9:$";;<=$ INTERESTS $ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$!;;>?@A>0@-BCD$ EEE>F& '**3>8GH$ NAME: DOB: DATE: 0+*)1('23*'%*(%&'4'+56(*(&6-'&(*7+)(&'23',(&+*(-'*'&+$812',(6%+1'23*'+56(*(&6&'9(1:;' Liquid Facelift Artefill BELOTERO Sculptra Restylane Perlane Juvéderm Radiesse BOTOX XEOMIN Droopy Brow, Jowls, Neck Wrinkles around the Mouth / Eyes Sagging Chin/Neckline Sun Damage Rosacea Broken Capillaries Acne Scars Enlarged Pores Brown Spots Red Spots Fine lines & Wrinkles Uneven Texture Fractional Laser Resurfacing (Fraxel /Thermage ) Skin Tightening PhotoRejuvenation (IPL) Medical Skin Care Dark Circles Spider Veins Facial Veins Sclerotherapy Cellulite Mesotherapy Lipodissolve Hyperhidrosis (excessive sweating) Laser Hair Removal Body Sculpting Stubborn Fat Laser Lipo Fat Transfer Stubborn Acne Permanent Cosmetics Vaginal Rejuvenation Hymen Restoration G-Spot Enhancement Excessive or Uneven Labia Labiaplasty My specific concerns: 1. Do you have any history of scarring of your skin? No Yes 2. Have you ever had a blood hormonal work up? No Yes 3. Have you ever had a laser procedure? No Yes 4. Ever had skin resurfacing/chemical peels? No Yes 5. History of cold sore/herpes/recurrent skin infection? No Yes 6. History of neurologic disease or muscle weakness? No Yes 7. History of poor or slow healing/keloid scars? No Yes 8. History of bruising or bleeding disorder? No Yes 9. History of skin cancer or suspicious moles? No Yes 10. Taking gingko, vitamins or any other supplements? No Yes 11. Taking prescription medications/alcohol regularly? No Yes 12. Any allergies to medications/latex/sulfites? No Yes <(%16"'<+&6*2'=>1(%&(')+*)1('*')$81(6(?' 13. Taken Accutane (isotretinoin) No Yes 14. Using Retin-A or alpha/beta hydroxyl acids? No Yes FOR WOMEN ONLY (N/A = not applicable): 15. When was your last period 16. Was it normal? N/A No Yes 17. Are you pregnant? N/A No Yes 18. Are you trying to get pregnant? N/A No Yes 19. Using anything to prevent pregnancy? N/A No Yes 20. History of polycystic ovaries? N/A No Yes 21. Melasma (mask of pregnancy)? N/A No Yes 22. Change in skin color with pregnancy? N/A No Yes I have answered all questions truthfully to the best of my ability. I have had the opportunity to ask about any question that was unclear and have this explained to me to my satisfaction. I will not hold anyone responsible for any adverse reaction that I may have as a result of any false information or information I have not disclosed. Client Signature: Date: Let New Beginnings Bring Out The Best In You! Ministering the Love of God Through Beauty! Thomas Theocharides, MD / rev:

2 HEALTH QUESTIONS!"$%&'!"()"%*+,(&-'./!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"$%&'($)*+,$-.&/$01&*2/$34$"5567$ $ NAME: DOB: AGE: PERSONAL PAST HISTORY (circle one for each number: N = no, Y = yes,? = not sure) 1. Asthma N Y? 2. Angina N Y? 3. Heart attack/murmur N Y? 4. Mitral valve prolapse N Y? 5. High blood pressure/stroke N Y? 6. Blood clots (legs or lungs) N Y? 7. Diabetes N Y? 8. Lupus/Collagen Vascular dis N Y? 9. Cancer N Y? 10. Thyroid disease/goiter N Y? 11. Anemia N Y? 12. Blood transfusion N Y? 13. Reflux/hiatal hernia/ulcers N Y? 14. Hepatitis/Jaundice N Y? 15. Alcoholism N Y? 16. Drug dependency/abuse N Y? 17. Nervous breakdown N Y? 18. Other past problem not listed N Y? CURRENT MEDICATIONS, VITAMINS, & SUPPLEMENTS if none check here: (include ALL vitamins, herbs, hormones and nonprescription medications taken regularly) Drug Name Dosage How long Doctor Drug Name Dosage How long Doctor (1) (5) (2) (6) (3) (7) (4) (8) SURGERIES/HOSPITALIZATIONS/INJURIES/ILLNESSES if none check here: REASON/TYPE OF INJURY/HOSPITAL DATE REASON/TYPE OF INJURY/HOSPITAL DATE SOCIAL HISTORY HEALTH HABITS 1. Do you smoke? no yes 2. Drink any alcohol daily? no yes 3. Recreational drug use? no yes SYSTEM REVIEW: N = never had, P = previous problem, C = current problem 1. CONSTITUTIONAL a. Weakness or fatigue N P C b. Lightheadedness N P C c. Frequent bruising N P C 2. CARDIOVASCULAR a. Chest pain/pressure N P C b. Shortness of breath N P C c. Palpitations N P C d. Swelling of legs N P C 3. RESPIRATORY a. Chronic cough N P C b. Bloody phlegm N P C c. Wheezing/Congestion N P C 4. NEUROLOGIC a. Tremors or Seizures N P C b. Numbness N P C c. Difficulty walking N P C d. MS / ALS / weakness N P C 5. MENTAL/EMOTIONAL a. Depression N P C b. Frequent crying spells N P C c. Problematic anxiety N P C 6. ALLERGIES: Drug N P C Latex N P C Environmental N P C Other I have answered all questions truthfully to the best of my ability realizing that failure to disclose health information may increase my risks and/or result in complications. I will not hold anyone responsible for any adverse reaction resulting from any information I have not disclosed. DATE TODAY SIGNATURE:! Thomas Theocharides, MD / rev:

3 !"$%&'!"()"%*+,(&-'./!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"$%&$$'()*$+,-.$/0-(1.$23$"4456$ $ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$!44&789&:8+;<=$ >>>&?-@A11A1@B((C&0DE$ Determining Your Skin Type to Achieve Your Best Results NAME: DOB: - /19 DATE: - /! This is one of the most important parameters to maximize your benefit while minimizing your risk.! For each row, circle the one best answer to the question (you can circle two boxes together).! Please leave the bottom two rows blank Genetics + Results from Sun What is your eye color? Natural hair color? Color of nonexposed skin? Freckles on unexposed areas? Too long in the sun results in: What degree do you brown? How does your face react to sun? When did you last tan or use tanning cream? Do you expose the area to be treated to sun? TOTAL PER COLUMN NUMBERED TOTAL Light blue, Gray, Green Sandy Red Reddish Blue, Gray, Green Blonde Very pale Blue Dark Brown Brownish Black Chestnut or Dark blonde Dark Brown Black Pale with Beige tint Light Brown Dark Brown Many Several Few Incidental None Painful redness, blistering/peeling Hardly or not at all Blistering followed by peeling Light color tan Burns sometimes then peeling Reasonable tan Rarely burns Tan very easily Very sensitive Sensitive Normal Very resistant More than three months ago Grand Total: 2-3 months ago 1-2 months ago Less than one month ago Never had burns Turn dark brown quickly Never had a problem Less than two weeks ago Never Hardy ever Sometimes Often Always Burning Tanning Total Score Fitzpatrick Skin Type Always Rarely 0-7 I Mostly Difficult 8-16 II Occasionally Easily III Never Always IV over 30 V-VI Let Beginnings Aesthetic & Laser Bring Out The Best In You! Ministering the Love of God Through Beauty! Thomas Theocharides, MD / rev:

4 !"$%&'!"()"%*+,(&-'./!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"$%&$$'()*$+,-.$/0-(1.$23$"4456$ $ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$!44&789&:8+;<=$ >>>&?-@A11A1@B((C&0DE$ DEMOGRAPHICS 0(*&1%2'314*$%5+1' '67','89':*(4(*'5';('%,,*(&&(,<'==========================================================================================' Name: Birth date: - - Age: LAST FIRST MI MAIDEN/PREVIOUS Current Status: M / S / D / W / Address: City/State: Zip: Home: ( ) - Mobile: ( ) - E mail: Alt Employer: Phone: ( ) - Contact in case of Emergency: Phone: ( ) - SSN: - - Driver's Lic: >15%)5'314*$%5+1' Best way to be reached: Mobile Home Work E Mail Letter CIRCLE ALL THAT APPLY Best day and time to call for reminders/follow-up: If you are not in, with whom may we leave a message? No one / How may we confirm appointments / follow-up? (circle all that apply / cross out what must not be used) Call: Mobile / Home / Work Voice mail Text Message Letter Postcard How do you want to learn about specials, Open Houses, promotions, or the latest in aesthetics/wellness? No thank you / Voice mail Text Message Letter Postcard / Call: Mobile / Home / Work How did you find us? Referral Source: IF THE INTERNET, PLEASE LIST SITE AND/OR SEARCH WORDS Check here if you are a patient of Ocean Ob/Gyn Associates If someone recommended you, may we thank them? (Circle one) YES NO (I prefer to remain anonymous) Client Signature: Date: Let Beginnings Bring Out The Best In You! Ministering the Love of God Through Beauty! Thomas Theocharides, MD / rev:

5 BEGINNINGS AESTHETIC & LASER LLC 804 WEST PARK AVE, OCEAN, NJ RT 9 NORTH, HOWELL, NJ PHONE: FAX: THOMAS THEOCHARIDES M.D., F.A.C.O.G. PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION With my consent, Beginnings Aesthetic & Laser LLC may use and disclose protected health Information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Beginnings Aesthetic & Laser LLC Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. Beginnings Aesthetic & Laser LLC reserve the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Privacy Officer, Beginnings Aesthetic & Laser LLC, at 804 West Park Avenue, Ocean, NJ With my consent, Beginnings Aesthetic & Laser LLC may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. With my consent, Beginnings Aesthetic & Laser LLC may send an or mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. I have the right to request that Beginnings Aesthetic & Laser LLC restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Beginnings Aesthetic & Laser LLC use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Beginnings Aesthetic & Laser LLC may decline to provide treatment to me. Print Name of Patient or Legal Guardian Signature of Patient or Legal Guardian Patient s Name Date I ACKNOWLEDGE THAT I HAVE RECEIVED BEGINNINGS AESTHETIC & LASER LLC UNOTICE OF PRIVACY PRACTICESU POLICY (OR IT HAS BEEN MADE AVAILABLE TO ME) Patient s Name Date Rev:

6 Beginnings Aesthetic & Laser LLC Thank you for choosing Beginnings Aesthetic & Laser as your aesthetic care specialist. We consider it a privilege that you have chosen us for your aesthetic rejuvenation goals. Please read the below policies carefully.! Cancellation Policy!" $%&'" ()'* +,-".%/0 +*'1+ ()' $%&'" )'*12 3) -,/,-,4" /) 15)6 %77),/+-"/+1 %/0 +) '+,&,4" 8%/8"&&"0 %77),/+-"/+19)*)+5"*7%+,"/+1:6"%1;+5%+()'7&"%1"7*)$,0"+5")99,8"<=>5)'*%0$%/8"/)+,8",9()'%*"'/%?&"+) ;""7 ()'* %9+"* 5)'*1: 8%&& ABB2C@D2E@FG3H2 I9 /) *"7&( 8%&& +5" %/16"*,/J 1"*$,8" %+ ABB2A==2=KKB2!"$%&'((%)%*%+,-.--%/"*$0%12$%3'445%*662' %F/%77),/+-"/+,18)/1,0"*"0-,11"0,9<=>5)'* /)+,8",1/)+J,$"/)*,9()'%*"-)*"+5%/LM-,/'+"1&%+"9)*()'*%77),/+-"/+2 Financial Policy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`F3@ ZZZZZZZZZZZZZZZZZZZZZZZZZZZZ a35)-%135")85%*,0"1:]`b*"$xl2xm2xb