New Patient Information From

New Patient Information From
First Name*
(Required)
Middle Name
Last Name*
(Required)
Date of Birth (mm/dd/yyyy)*

MonthDayYear
(Required)
Social Security Number (last 4 digits)
Please enter a number less than or equal to 9999.
Email*
(Required)
Sex:*

MaleFemale
Marital Status:*

MarriedWidowSingleDivorced
Home#*
(Required)
Work#
Cell#
Florida Address:*
(Required)
City:*
(Required)
Zip:*
(Required)
Northern Address:
City:
State:
Zip:
Employer:
(Retired)Past Career:
Person Responsible for Payment:
Phone
In Case of Emergency:
Phone(Emergency)#
How did you hear about Dr Prysi? (Please give as much detail as you can)
Seminar
Website Name
Friend or Patient(name):
Physician(name):
Naples Daily NewsGulfshore LifeNaples Illustrated:Other
Have you visited Dr. Prysi's website (www.prysicosmetic.com)?

YesNo
Medical History
In this time of rapidly expanding medical knowledge and the increasing specialization associated there within, there exists a very real risk of the specialist physician not being aware of the general health and medical background of the patient. On occasion such information may critically affect what procedures we may safely undertake on you and under what circumstances. We therefore ask that you give us the following medical information.
General Health:*

GoodFairPoor
Recent Weight Change:*

YesNo
Do You Get Regular Physicals:*

YesNo
Height:
Weight:
Date of Check up(mm/dd/yyyy):

MonthDayYear
Date of Chest X-ray(mm/dd/yyyy):

MonthDayYear
Date of EKG(mm/dd/yyyy):

MonthDayYear
Date of Doctor(mm/dd/yyyy):

MonthDayYear
Serious Illnesses:
Surgery Type:
Date of Surgery (non cosmetic)(mm/dd/yyyy):

MonthDayYear
Complications of Surgery:
Past Injuries:
What is your consumption of?
Caffeine:
Tobacco:
Alcohol:
Please List All Medications You are Currently Taking:*
Please List Any Sensitivities or Medications You Have Had an Allergy to:*
Have you had any Cosmetic Surgery in the Past?

Yes.No.
Please select Yes indicating the following that you are currently or have ever been treated for and No for never:
Tuberculosis

Yes.No.
Cancer

Yes.No.
Diabetes

Yes.No.
Epilepsy

Yes.No.
Heart Disease

Yes.No.
High Blood Pressure

Yes.No.
Lung Disease

Yes.No.
Kidney Disease

Yes.No.
Mental Conditions

Yes.No.
Asthma

Yes.No.
Blood Disorder

Yes.No.
Consultation Questionaire
In which surgical procedure(s) are you interested? (Please check)
Face

Entire FaceMid FaceLower FaceSkin ResurfacingProtruding EarsNoseChinEyesLipsNeck
Body

LiposuctionThigh LiftArm LiftAbdominoplastyScar Revision
Breast

Breast AugmentationBreast LiftBreast Reduction
Other Procedure
What specifically do you wish to have corrected (i.e. what don't you like about the above condition(s)
When did you begin to consider surgical correction?
What is most important to you in your cosmetic surgery procedure?
Why have you decided to have it done at this point in time?
Have you consulted any other doctor about this? (When?)
Have you discussed this surgery with your family?

Yes.No.
Are they agreeable?

Yes.No.
Do you understand that the objective of any cosmetic operation is improvement in appearance, not perfection?

Yes.No.
Are you aware that the results of the operation might not fully meet your expectations?

Yes.No.
Have you had any previous cosmetic surgery?

Yes.No.
When, and what was done?
Who performed the surgery?
Where was it performed?
Where you satisfied with the results?
If not, why?
Patient Computer Imaging
In the course of consultation and discussion with Dr. Prysi, I may have been shown or may be shown or provided certain brochures, and/or pictures on an electronic computer imaging device. I understand that those pictures and alteration of those pictures seen are solely for the purpose of illustration/discussion and to provide improved communication with the doctor. I do understand that the outcome of any type of surgical procedure is directly related to my individual characteristics and health. I further understand and acknowledge that because of the obvious significant differences in how living tissue react to surgery, there may be no relationship between the electronic images created, and my actual final surgical result.

Use of the computer imaging system offers an opportunity for me to discuss my desires and to allow an improved communication with the doctor.
(Please initial 1 of the following)*

I hereby DO grant permission for the use of illustrations, photographs or imaging records created in my case for use in scientific and professional journals and presentations at any time during or after treatment, with complete confidentiality of my identity.I hereby DO NOT grant permission for the use of any illustrations, photographs or imaging records created in my case for use in scientific and professional journals and presentations at any time during or after treatment, with complete confidentiality of my identity.
Patient Signature*
(Required)
Witness Signature
Date(mm/dd/yyyy)*

MonthDayYear
(Required)
Should be Empty:

New Patient Information From

Medical History

Consultation Questionaire

Patient Computer Imaging