Pristine Med Spa

Patient's Questionnaire
Contact Us
Leave this field blank

Patient Questionnaire


Medical History

Surgical History

Dermatologic History

Patient Skin Typing Evaluation Form

This information will help our office to better evaluate your skin type so the treatments will be safer and more effective. By using the information you provide on this form, we can better prepare to provide you with the best care.

Genetic Disposition

Notice of Privacy Practices



We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. This Notice applies to all records of your care generated and maintained by this medical spa.

We are required by law to: 1) make sure that medical information that identifies you is kept private; 2) make available to you this Notice of our legal and privacy practices with respect to medical information about you; and 3) follow the terms of the Notice that is currently in effect.


  • We may disclose medical information about you to doctors, nurses, or other personnel involved in taking care of you. We may also disclose medical information to people outside the medical group, such as your family members, specialist or others who are involved in providing services that are part of your care.
  • We may use or disclose medical information about you for operations. These may include use of information to evaluate the performance of our staff, effectiveness of programs, and ways to improve care and services we offer. These uses and disclosures are necessary to ensure that all of our patients receive quality care.
  • We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or care.
  • We may use or disclose medical information to tell you about or recommend possible treatment options or alternatives, and about health-related benefits, services, events, and activities that may be of interest to you.
  • We may disclose medical information about you to other healthcare providers in the event you need emergency care.
  • We may disclose medical information about you as required by federal, state, or local law.
  • We may use or disclose medical information to a public health organization or federal organization when necessary to prevent a serious threat to your health and safety or health and safety of the public or another person.
  • We may disclose medical information about you in special situations such as for workers’ compensation programs, as required by military command authorities or the Department of Veterans Affairs, in response to a court or administrative order, or for the public health activities.

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. You may later revoke this permission in writing at any time.


  • You have the right to review and receive a copy of medical information that may be used to make decisions about your care. Usually this includes medical information and treatments. You must submit a written request to review and cop your medical information. We will charge a fee of $25 for the first 20 pages for the costs of supplying a copy of the records and an additional 50¢ per page after 20 pages. You will receive your records in 15 business days.
  • You have the right to ask us to amend medical information that you feel is incorrect or incomplete. Your request for an amendment must be submitted in writing and must provide a reason that supports your request.
  • We may deny your request for amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if the information: 1) was not created by us; 2) is not part of the medical information kept by or for us; 3) is not part of the information which you are which you are permitted to inspect and copy; or 4) is accurate and complete.
  • You have the right to request an “accounting of disclosures.” This is a list of disclosures we have made of medical information about you, with some exceptions. The exceptions are governed by federal health privacy law, and include: 1) routine disclosures for treatment, payment, and operations conducted pursuant to your signed consent form; and 2) disclosures to you. You must submit a written request. The request must state a time period that may be longer than six years and may not include dates before April 14, 2003, when current federal health privacy laws became effective.
  • You have the right to request restrictions or limitations on the use or disclosure of medical information about you. You must submit a written request for restriction that specifies: 1) what information you want to limit; 2) whether you want to limit our use, disclosure, or both; and 3) to whom you want the limits to apply. We reserve the right to refuse your restriction if it is in conflict with providing you quality healthcare or in an emergency situation.
  • You have the right to request that we communicate with you about medical matters in a certain way or at a certain location, such as only work or by mail, etc. You must submit a written request for confidential communications restrictions, specifying how or where you wish to be contacted. We will accommodate reasonable requests.
  • You have the right to possess a copy of the Privacy Notice upon request. You may receive a paper copy of this notice, or you can also obtain a copy of the Notice at our office.
  • You have the right to file a complaint if you believe your rights to privacy have been violated. All complaints must be submitted in writing. All complaints will be investigated. No personal issue will be raised for filing a complaint.

To make a compliment or a complaint regarding this registered laser facility, contact the Department of State Health Services at this toll-free number:


Or call the Texas Medical Board at their hotline: 1-800-201-9353

Changes To This Notice

We reserve the right to change this Notice at any time. We will notify you by email or phone in the case that happens.

Acknowledgment Of Receipt

Notice of Privacy provides information about how we may use and disclose your protected health information.

In addition to the copy we are providing you, copies of the current notice are available at our office.