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Trust Your Face To An Expert, Trust Your Face To A Facial Plastic Surgeon

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New Patient Forms

Historical Data Sheet



Patient Name *





Which surgical procedure(s) are you interested in?

Rhinoplasty (nose)Forehead liftRemoval of cysts, moles, etcFotoFacial RFFace or Neck LiftCollagen/Botox/Restylane EyelidsScar RevisionLiposuctionProtruding earsSkin ResurfacingSkin CareHair RemovalSkin CancerLip enhancementOther

Other

Have you consulted another doctor in regards to this type of surgical procedure?

YesNo



Are you allergic to Latex?*

YesNo

Any known drug allergies?*

YesNo






POST COVID19 PATIENT PROTOCOLS

**PLEASE RESCHEDULE YOUR APPOINTMENT IF:

  1. You have been a part of a large gathering in the past two weeks (other than immediate family).
  2. You have travelled: to Chicago, or any other high COVID19 risk area, or anywhere by plane, within the last two weeks.
  3. You are sick now with fever, cold or flu-like symptoms or loss of taste or smell.
  4. You have NOT practiced Social Distancing for at least the past two weeks.

IF YOU ARE A HIGH-RISK PATIENT, FOR YOUR OWN SAFETY, WE RECOMMEND YOU FOLLOW STRICT SOCIAL DISTANCING AND CONSIDER NOT COMING INTO THE OFFICE AT THIS TIME:

Examples of high risk are Greater than 70 years of age.
Heart, Kidney or Lung Disease such as Asthma & COPD. Diabetes or other Immunocompromised status.

WHEN YOU ARRIVE AT REJUVENIS

  1. Call this number: 217-419-8418 when you arrive at the building.
  2. Please wait in your vehicle until we contact you by phone or text to let you know when you can enter the building.
  3. Mask/Face covering is required.
  4. Only patients are allowed (no visitors/children) and only one patient at a time per room.
  5. We may check your temperature.
  6. Please clean your hands with a provided sanitizing wipe at the reception window.