Today's Date:
*
/
Month
/
Day
Year
Date
He/Him
She/Her
They/Them
First Name:
*
Last:
*
M.I.
Street Address:
*
City:
*
State:
*
Zip Code:
*
Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Sex:
Birthdate:
*
/
Month
/
Day
Year
Date
Social Security #:
*
000-00-0000
Ethnicity:
*
Please Select
White
African American
Hispanic/Latino
Asian
American Indian
Alaska Native
Native Hawaiian
Pacific Islander
Other
Procedure(s) of Interest:
*
OCCUPATION
Insurance
Employer:
Employer Address:
INSURANCE
Primary Insurance Co.
Name of Policy Holder/Guarantor:
Relation to Patient:
Self
Spouse
Parent
Other
ID #:
Group #:
Pharmacy
Pharmacy Name:
*
Pharmacy Phone #:
*
Please enter a valid phone number.
City:
*
Emergency Contact
Name:
*
Relation:
*
Phone Number:
*
Please enter a valid phone number.
Dr. Gerstle is interested in knowing about your general health so he may plan your surgery/treatment as carefully as possible. This form is CONFIDENTIAL.
General Health:
*
Excellent
Good
Fair
Poor
Marital Status:
*
Single
Married
Height:
*
Weight (lbs):
*
Drug Allergies?
*
Yes
No
If yes, please list medication and reaction.
Other allergies?
Latex
Adhesive Tape
Contrast Dye
Iodine
Seafood
Metal
Other
Any medications, vitamins, over-the-counter herbal preparations/supplements? If yes, please list below the name of medication, strength (mg), frequency, and reason for taking it.
Have any family history of cancer, heart trouble, or stroke? Yes or No (Specify)
*
Do you engage in a regular exercise program?
*
Yes
No
Consume regular amounts of alcoholic beverages?
*
Yes
No
Amount and frequency?
Use tobacco/nicotine products?
*
Yes
No
Drug Use?
*
Yes
No
If yes, please specify.
Do you have a skincare regimen?
*
Yes
No
If yes, please specify.
Have any current or previous use of cortisone/steroids?
*
Yes
No
If yes, please specify.
Do you have problems with general anesthesia?
*
Yes
No
Any family history of issues with anesthesia? If yes, please specify.
General Health
Please check yes or no if any of the following apply:
*
Yes
No
Serious illness lately
Anemia
Nervousness
Drug Habit/addiction
Psychiatric treatment
Blackouts or epilepsy
Shortness of breath
High blood pressure
Diabetes
Thyroid problems
Susceptible to cold sores
Hidradenitis suppurativa
Heart
Please check yes or no if any of the following apply:
*
Yes
No
Heart Trouble
Heart Attack
Palpitations/irregular or extra beats
Angina (chest pain)
Abnormal EKG
Rheumatic heart disease
Heart failure
Lungs
Please check yes or no if any of the following apply:
*
Yes
No
Asthma
Bronchitis
Tuberculosis
Pneumonia
Smoker's cough
Emphysema
Kidneys
Please check yes or no if any of the following apply:
*
Yes
No
Infections
Kidney Damage
Kidney failure
Blood
Please check yes or no if any of the following apply:
*
Yes
No
Bleeding tendency
Blood transfusions
Blood Clots/DVT
Breast
Please check yes or no if any of the following apply:
*
Yes
No
Cyst, tumor, or lump
Breast biopsy
Nipple discharge
Mammogram
Eyes
Please check yes or no if any of the following apply:
*
Yes
No
Visual Problems
Wear contacts
Wear glasses
Use eye drops
Nose
Please check yes or no if any of the following apply:
*
Yes
No
Broken nose
Difficulty breathing
Use nose spray
Liver
Please check yes or no if any of the following apply:
*
Yes
No
Hepatitis
Cirrhosis (Alcohol disease)
Intestinal
Please check yes or no if any of the following apply:
*
Yes
No
Stomach Ulcers
Colitis
Gallstones
Do you have an Advanced Directive?
*
Yes
No
Would you like a copy of our Patient Rights and Responsibilities?
*
Yes
No
Primary Care Physician Name:
Primary Care Physician Phone #:
Please enter a valid phone number.
Date of your last physical exam:
/
Month
/
Day
Year
Date
Date of most recent mammogram:
/
Month
/
Day
Year
Date
Date of any recent lab work (if applicable):
/
Month
/
Day
Year
Date
How did you hear about us?
*
Friend
Doctor
Facebook/Instagram
Internet (Google)
Payment Policy
All professional services rendered are charged to the patient and are due and payable prior to the time of service. Past due accounts greater than thirty (30) days will be subject to an interest fee of 1.5% per month. Past due accounts may also be subject to attorney’s fees, collection fees, legal fees, and / or court costs incurred as a result of our attempt to collect the debt. A service fee of $25.00 will be assessed for each returned check. I understand that I am financially responsible for all payments related to my treatment. A copy of this signature is as valid as the original. I understand that all payments for consultations, procedures, and surgery deposits are non-refundable. Payments may be applied toward future treatments or procedures.
Signature of Patient or Personal Representative:
*
Date:
*
/
Month
/
Day
Year
Date
Signature of Policy Holder:
*
Date:
*
/
Month
/
Day
Year
Date
Consent to Photograph
I understand that photographs may be taken before and after my treatment or procedure at Lexington Plastic Surgery™ for medical documentation, educational, and/or marketing purposes. I authorize the use of these photographs for any lawful purpose, including display on the practice’s website, social media, and other promotional materials, only as approved by Dr. Gerstle. I understand that every effort will be made to maintain my privacy and confidentiality. Identifying features, such as my face or tattoos, will not be used without my additional written consent. I understand that I may withdraw my consent for the use of my photographs for marketing purposes at any time by submitting a written request to Lexington Plastic Surgery™
Signature of Patient or Personal Representative:
*
Date:
*
/
Month
/
Day
Year
Date
Type a question:
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