New Patient Form

NEW PATIENT FORM
Patient Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital status*
What is your height?*
What is your current weight?*
Select Reason for Visit*

Arm LiftBreast AugmentationBreast LiftBreast ReductionBreast RevisionImplant RemovalBrow LiftBuccal Fat RemovalChemical PeelEyelid SurgeryEarlobe ReductionFace/Neck LiftFacial ImplantsForehead ReductionHair RestorationInjectables- neurotoxins/fillersLabiaplastyLip LiftLiposuctionLower Body LiftMicroneedlingMommy MakeoverRhinoplastyThigh LiftTummy TuckOther
History (fill out why you are here, what brought you to want this procedure etc. )*
For Breast Augmentation / Lift:
For Tummy Tucks:
For Mommy Makeover:
For Chemical Peel: Do you regularly use any creams or medications on your skin?
i.e. scars, fine lines, wrinkles, pore size, texture, sun spots, etc.
For Rhinoplasty: Do you have difficulty breathing?
i.e. scars, fine lines, wrinkles, pore size, texture, sun spots, etc.
For Injectables / Neurotoxins / Fillers: Do you currently take any blood thinners or using facial creams? (ex. Aspirin, Vitamin E, Retinol, etc.)
i.e. scars, fine lines, wrinkles, pore size, texture, sun spots, etc.
For Implant Removal: Do you have any pain or discomfort?
i.e. scars, fine lines, wrinkles, pore size, texture, sun spots, etc.
For Liposuction: What areas do you wish to liposuction?
i.e. scars, fine lines, wrinkles, pore size, texture, sun spots, etc.
For Lower Body Lift: What are your concerns for your abdomen? (ex. stretch marks, excess fat or skin, etc.)
i.e. scars, fine lines, wrinkles, pore size, texture, sun spots, etc.
Primary Care Physician
Physician Name*

First NameLast Name
Phone Number*
How Did You Hear About Our Office? *

WebsiteFacebookInstagramSaw Your SignOther/Personal Referral
Emergency Contact
Emergency Contact Name*
Relationship*
Work Number*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Preferred Pharmacy Information
Pharmacy Name*
Address*
Phone*
Please enter a valid phone number.
Medical History
No significant past medical history
Medical History (Enter details below)

ArthritisAsthma or Lung DiseaseCancerDiabetesHeart ConditionsHigh CholesterolHypertensionHypotensionKidney DiseaseLumbagoLumbosacral root lesionsLupusPeripheral neuropathySeizures or EpilepsyScoliosisSpinal stenosisStrokeThyroid DiseaseOther
Enter details of medical history
Other Medical History Not Listed Above.
Past Surgical History
Patient has no Previous Surgeries
Medical History (Enter details below)

Abdominal SurgeryAppendectomyArm LiftBladder Repair/SuspensionBody LiftBreast AugmentationBotoxBreast LiftBreast ReductionBrow LiftCardiac Surgery including StentsCesarean SectionCholecystectomyEyelid SurgeryFace LiftFacial FillersHernia RepairHysterectomyJoint ReplacementLiposuctionNeck LiftOophorectomyOrgan TransplantSpinal SurgerySplenectomyThigh LiftTonsillectomyTummy TuckOther
Please include the year you completed your past surgery. Please list out the procedure(s) next to the year if multiple surgeries have been selected.
Allergies
I Have No Known Allergies
Allergies

PenicillinSulfaCephalosporinsQuinolonesIodineLatexDairyOther
What reactions did you have, if any?
Current Medications
Classes of Medications

Blood ThinnersChemotherapyDiabetes MedicationsPsychiatric MedicationsRheumatoid MedicationStatinsSteroidsNo Current MedicationsOther
Family History
No significant family history
Family History

DeceasedDiabetesHypertensionHypotensionStrokeCancerEnvironmental AllergiesGERDSkin DisordersHeart DiseaseLung DiseaseAsthmaEmphysemaObesityGI ProblemsAuto-Immune DiseaseBlood DisorderLipid DisordersBronchitisArthritisCardiovascular DiseaseHeadachesRheumatoid ArthritisPkd
Social History: Smoking
Have You Ever Been A Smoker?*

YesNo
Are You Currently Smoking?*

YesNo
If You Answered No, When Did You Quit?
If You Answered Yes, How Much Do You Smoke?

1-4 cigarettes per dayMore than 5 cigarettes per daySocial Smoking
Have you been offered Tobacco Cessation Counseling?

YesNo
Do you vape?

YesNo
Do You Use Any Form of Nicotine or Nicotine Replacement Therapy. If So, What Products?

GumInhalersLozengesNasal SpraySkin PatchOther
Social History: Alcohol, Drugs, Occupation, Hobbies
Do you drink alcohol?*

YesNo
How Much Alcohol Do You Drink?

Socially, On Occasion1-2 Drinks Per Day3-5 Drink Per DayMore Than 5 Drinks Per Day
Do You Use Recreational Drugs?*

YesNo
Drug Usage Details

CocaineHeroinCannabisEcstasyLSDBenzodiazepinesPCPAdderallBarbituratesAmphetaminesOpiatesKetamineMescalineASDF
What Are Your Hobbies / Athletic Activities?*
Occupation (Answering This Question Helps Guide The Surgical Recovery Discussion)*
Other: (Must Show Valid ID)
Other: (Must Show Valid ID)
Signature

Clear
Should be Empty:

Primary Care Physician

Emergency Contact

Preferred Pharmacy Information

Medical History

Past Surgical History

Allergies

Current Medications

Family History

Social History: Smoking

Social History: Alcohol, Drugs, Occupation, Hobbies