PATIENT REGISTRATION FORM

NAME*
DOB*
SSN
GENDER*

MALEFEMALENONBINARYTRANSGENDEROther
MARITAL STATUS*

SINGLEMARRIEDOther
ETHNICITY
ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CELLPHONE*
EMAIL*
example@example.com
OCCUPATION
EMPLOYER
EMERGENCY CONTACT
EMERGENCY CONTACT - RELATIONSHIP
EMERGENCY CONTACT - ADDRESS
EMERGENCY CONTACT - CELLPHONE
EMERGENCY CONTACT - EMAIL
example@example.com
REFERRAL SOURCE

GOOGLEFACEBOOKINSTAGRAMYELPNEXTDOORYOUTUBEPRINT/FLYERRADIOTVREAL SELFMAGAZINEFRIEND/RELATIVE/DOCTOROther
IF REFERRED BY FRIEND/RELATIVE/DOCTOR, PLEASE INCLUDE NAME:
PRIMARY CARE PHYSICIAN
PHONE
LIST OF PHYSICIANS/SPECIALTY
PHARMACY NAME
ADDRESS
PHONE NUMBER
REASON FOR CONSULTATION*
HEIGHT*
WEIGHT*
DATE OF LAST PHYSICAL EXAM

MonthDayYear
Date
DATE OF LAST MAMMOGRAM (IF APPLICABLE)

MonthDayYear
Date
ALLERGIES? PLEASE LIST ALLERGIES AND DESCRIBE TYPE OF REACTION
PLEASE INDICATE IF YOU HAVE A LATEX ALLERGY

YESNO
PLEASE SHARE YOUR CURRENT MEDICAL CONDITIONS (High Blood pressure, Diabetes, etc)*
PLEASE SHARE YOUR PAST SURGICAL HISTORY*
PLEASE LIST CURRENT MEDICATIONS, VITAMINS, HORMONES, HERBAL SUPPLEMENTS, ETC *
PLEASE INDICATE IF YOU TAKE ASPIRIN OR IBUPROFEN

YESNO
PLEASE INDICATE IF YOU ARE ON BIRTH CONTROL/HORMONE REPLACEMENT

YESNO
HAVE YOU BEEN ON SUBOXONE / METHADONE /OPIOID / HEROINE IN LAST 6 MONTHS?

YESNO
HAVE YOU BEEN ON STEROIDS / CORTISONE IN THE LAST 6 MONTHS

YESNO
HAVE YOU BEEN ON ACCUTANE / RETIN-A IN THE LAST 6 MONTHS

YESNO

PLEASE SHARE YOUR CONSUMPTION OF THE FOLLOWING

PLEASE INDICATE IF YOU HAVE A HISTORY OF THE FOLLOWING:

BLEEDING/BRUISINGCANCERHIGH BLOOD PRESSURESEIZURES/STROKEPSYCHOSISMISCARRIAGEHEART DISEASEHERPES/COLD SORESBLOOD CLOT(S)CHRONIC PAINDRY EYESSLEEP APNEAKIDNEY DISEASEASTHMA/LUNG DISEASETHYROID DISEASEHIV/AIDSANXIETYCONNECTIVE TISSUE DISEASELUPUSREACTION TO ANESTHESIADEPRESSIONDIABETESMRSA (STAPH INFECTION)KELOIDS/POOR SCARRING
PLEASE INDICATE IF YOU HAVE A FAMILY HISTORY OF

BREAST CANCERREACTION TO ANESTHESIABLOOD CLOT(S)HEART DISEASECONNECTIVE TISSUE DISEASELUPUS
IF APPLICABLE, ARE YOU CURRENTLY PREGNANT OR LACTATING

YESNO
DO YOU CURRENTLY HAVE PERMANENT MAKEUP / MICROBLADING

YESNO
HAVE YOU HAD A WAX OR APPLIED DEPILATORY IN THE PAST 4 WEEKS

YESNO

PLEASE INDICATE IF YOU HAVE HAD THE FOLLOWING PROCEDURES

HAVE YOU UNDERGONE LASER TREATMENT IN THE LAST 3 MONTHS

YESNO
HAVE YOU UNDERGONE MICRODERMABRASION IN THE PAST 3 MONTHS

YESNO
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
PRACTICE NAME
PHYSICIAN
ADDRESS
PHONE
PRACTICE EMAIL
example@example.com
I hereby certify that all of the information stated above is true. I further agree that a photocopy or scanned electric copy of this agreement shall be as valid as the original. Unless otherwise stated, I agree to receive information (quarterly newsletter, special events, promotions, healthcare tips, etc) from Landford Plastic Surgery via electronic mail or text message.

By representation of signature below, / hereby authorize the above stated office to forward my medical records to:
Patient/Guardian Signature*

Clear
Printed Name*
Date*

MonthDayYear
Date
Should be Empty: