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217-398-4856
Trust Your Face To An Expert, Trust Your Face To A Facial Plastic Surgeon

Resource Center

New Patient Forms

Personal Physicians








May we notify him/her of your visit or upcoming surgery?

YesNo

Have you ever or are you currently being treated by a psychiatrist or psychologist?

YesNo


Phone Number

- -





Please check the appropriate responses for the following "Yes" / "No" questions in this section

Have you ever had any reaction to local or general anesthesia?

YesNo


Ever taken Accutane?

YesNo


Use Nicorette/Nicotine patches?

YesNo

Take aspirin regularly?

YesNo


Caffeinated Drinks:

YesNo








Are you currently or have you ever been treated or diagnosed for any of the following? (Please mark all that apply).

Check All That Apply

Rheumatic HeartThyroid disorder/ GoiterDiabetesPoor circulationHeart murmrAngina/Chest painHeart attackHigh Blood pressureStrokeHeadaches/MigrainesChronic FatigueFibromyalgiaLatex allergyCold Sores/Fever blistersKidney DiseaseAsthmaHay fever/ Nasal allergiesLung/Chest problemsHerniaUlcersArthritisLupus/ SclerodermaHIV/AIDSGall bladder disordersDepressionNervous breakdownPsychiatric or "nerve" problemsSeizures/ ConvulsionsAnemiaBleeding tendenciesScarringStaph InfectionVision changesEye problemsSkin Conditions (irritation/rashes/infections)AlcoholRecreational DrugsParalysis/ NumbBell's PalsyEasy BruisingFibrocystic disease

Hepatitis/ Jaundice

HepatitisJaundiceNeither

Hepatitis Type:

ABCNot applicable

Cancer:

YesNo

If yes, which type?

SkinOther






Do you have any other medical problems that have not been covered?

YesNo


Do you realize every operation is followed by a period of healing before the tissue returns to normal and a final result is apparent?

YesNo

Do you understand that the objective of any cosmetic surgery is improvement in appearance, not perfection?

YesNo










Confidiential Record:


Information contained here will not be released except when you have authorized us to do so. Please answer all questions to the best of your knowledge. The information provided by you will be used by your doctor in making decisions regarding your care.



I authorize my physician and/or administrative and clinical staff to telphone or otherwise contact me (or the responsible party) regarding appointments, treatment information, or any other details related to patient therapy and treatment.

Electronic Signature *

Date



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.