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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

    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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