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New Patient Forms

Historical Data Sheet



Patient Name *





Which surgical procedure(s) are you interested in?

 Rhinoplasty (nose) Forehead lift Removal of cysts, moles, etc FotoFacial RF Face or Neck Lift Collagen/Botox/Restylane Eyelids Scar Revision Liposuction Protruding ears Skin Resurfacing Skin Care Hair Removal Skin Cancer Lip enhancement Other

Other

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

 Yes No



Are you allergic to Latex?*

 Yes No

Any known drug allergies?*

 Yes No