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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



About author - Dr. Russo

Dr. Russo

Dr. Russo is the founder of Rejuvenis Med Spa. He developed a passion for lasers, fillers, and other non-cosmetic treatments during his over 30 years of practice in Champaign-Urbana. He started his career after completing an AAFPRS fellowship in Facial Plastic Surgery. After many years of managing a busy surgical practice and med spa, Dr. Russo focuses his interest and practice on non and minimally-invasive facial and skin rejuvenation. Visit Rejuvenis Beauty today for experienced care in health, beauty, and wellness!

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