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Resource Center

New Patient Forms

Personal Physicians








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

 Yes No

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

 Yes No


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?

 Yes No


Ever taken Accutane?

 Yes No


Use Nicorette/Nicotine patches?

 Yes No

Take aspirin regularly?

 Yes No


Caffeinated Drinks:

 Yes No








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 Heart Thyroid disorder/ Goiter Diabetes Poor circulation Heart murmr Angina/Chest pain Heart attack High Blood pressure Stroke Headaches/Migraines Chronic Fatigue Fibromyalgia Latex allergy Cold Sores/Fever blisters Kidney Disease Asthma Hay fever/ Nasal allergies Lung/Chest problems Hernia Ulcers Arthritis Lupus/ Scleroderma HIV/AIDS Gall bladder disorders Depression Nervous breakdown Psychiatric or "nerve" problems Seizures/ Convulsions Anemia Bleeding tendencies Scarring Staph Infection Vision changes Eye problems Skin Conditions (irritation/rashes/infections) Alcohol Recreational Drugs Paralysis/ Numb Bell's Palsy Easy Bruising Fibrocystic disease

Hepatitis/ Jaundice

 Hepatitis Jaundice Neither

Hepatitis Type:

 A B C Not applicable

Cancer:

 Yes No

If yes, which type?

 Skin Other






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

 Yes No


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

 Yes No

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

 Yes No










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