Medical Procedures Patient Intake Form

Medical Procedures Patient Intake Form
Patient Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemaleOther
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address Line 2

State

Zip CodeCountry
What procedure or service you're going to get?
Height
Weight
Are you pregnant or breastfeeding?

YesNo
Family planning method :
Tobacco amount per day:
Are you drinking alcohol?

YesNo
Are you under any medication for the last 6 months? If yes, please indicate and explain it below:
Are you taking any of the following medications?

AntibioiticsAnticoagulantsHerbal medicinesHigh blood pressure medicationsSteroidsTranquilizersAspirinNitroglycerinDigitalisOther
Do you have any known allergies to food, cosmetics and drugs and medicine? If yes, please indicate and explain it below:
Do you have any medical conditions that the clinic should be aware of? If yes, please indicate and explain it below:
Do you have any of the following condition?

Bleeding disorderLeukemiaCancerViral infectionDiabetes MellitusHeart problemsHIVHepatitisLiver diseaseRheumatic FeverSicke Cell AnemiaSeizuresEpilepsyOther
Do you have symptoms of COVID-19 for the past 7 days?

YesNo
Have you had any type of surgery before? If so, please indicate.
Were you exposed to someone with COVID-19 for the past 14 days?

YesNo
Have you been vaccinated for COVID-19?

YesNo
How did you hear about us?

Social MediaTV CommercialYouTubeOnline AdsPosters/BannersMagazinesNewspaperReferralOther
Acknowledgment and Waiver
I understand that this procedure cannot guarantee 100% expeted results.

I understand that post-operative care are needed in order to fully achieve the goal. I confirm that it is my responsibility to follow the treatments and follow-ups after the procedure.

I permit the clinic to take photographs and videos of the procedure for educational purposes only.

I allow this clinic to use my photographs for "before and after results" for marketing and advertising purposes.

I hereby release this clinic and travel agency for any indemnification or hold them harmless agains physical damage, personal injury, or accidents that might happen during and after the procedure.

I confirm that all information I provided in this form is accurate and true.
Patient Signature

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Date Signed

MonthDayYear
Date
Should be Empty:

Medical Procedures Patient Intake Form

Patient Information

Acknowledgment and Waiver