RejuvaMAX Enhancement Intake Form

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
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform