RejuvaMAX Enhancement Intake Form
The medical information you supply is subject to ALL patient/doctor privilege laws
Date of Birth
*
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Employment Status - Employer? Self-Employed? Retired?
Emergency contact
Full Name
Phone Number
Relationship to patient
Parent
Significant Other
Sibling
Child
Friend
Other
MEDICAL HISTORY
Do you have any allergies? Please list
Are you allergic to Lidocaine or local anesthetics?
Yes
No
Are you allergic or sensitive to Hyaluronic Acid fillers?
Yes
No
List All Medical Conditions
List All Current medications including prescriptions, over-the-counter and supplementsa
Are you currently taking any prescription blood-thinners such as warfarin, Eliquis, Xarelto etc?
Yes
No
Are you currently taking any OTC aspirin or non-steroidal anti-inflammatory drugs?
Yes
No
Are you currently taking Vitamin E supplements or herbal supplements containing garlic or ginkgo bilboa?
Yes
No
Do you have diabetes?
Yes
No
Do you suffer from Porphyria?
Yes
No
Do you have a tendency to form keloids or hypertrophic scarring?
Yes
No
Do you have genital herpes or any sexually transmitted disease?
Yes
No
If yes, please provide details of the herpes or STD. How often have outbreaks? Treatment? Current outbreak?
Surgical History
Additional Comments
SEXUAL HISTORY
Please describe why you are seeking Penile Enhancement Procedure? Concerns about Girth? Length? Irregular shape....?
Have you tried any treatments or penis enlargement treatments in the past?
Sudden
Gradual
How long have you been concerned about penis size and what have your tried in the past?
Please check all conditions that apply:
Peyronie's Disease
Erectile Dysfunction
Penile size concerns
Irregularities in penile shaft
Penis Girth
Penis Length
Premature ejaculation
Are you circumcised?
Yes
No
On a scale of 0 to 100%, how firm are your natural erections. Are the firm enough for penetration during sexual intercourse?
How frequently do you get morning erections?
Dialy
Weelkly
Monthly
Rarely
Never
Can you feel a lump or scar tissue inside your penis? If yes, please describe size and location.
Do you experience pain or discomfort when you have an erection?
Yes
No
Do you experience pain or discomfort during sexual intercourse?
Yes
No
Can not have intercourse
Please tell us your reason you are seeking Penis Enhancement and your expectations
Are you seeking Penis Enhancement because you are troubled by the size of your penis or because your partner is having issues (woman's vaginal area stretches out with childbirth and age)
Individual concerns about size and appearance
To satisfy partner
Both
Additional comments:
SOCIAL HISTORY
Social History
Single
Dating
Married
Divorced
Widowed
Do you Smoke
Yes
No
Do you consume alcoholic beverages?
Yes
No
Do you use marijuana, cocaine or other similar drugs?
Yes
No
Submit
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