Surgical Form Packet

I agree and understand that I will not drive myself home after having my tumescent lipo procedure. First Name Last Name is driving me home. Their telephone number is Phone Number and I have made arrangements to have First Name Last Name stay with me after the procedure, for the first 24 hours..
Patient Name:*
Patient Signature:*

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Date:

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Date
Witness Name:
Witness Signature:

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Date:

MonthDayYear
Date

Patient Name:*
Age:
Have you had a hysterectomy or already gone through menopause? (If "Yes," you do not need to fill out this form)

YesNo
Are you pregnant or could you be pregnant?

YesNo
Are you breast feeding?

YesNo
(If you suspect you may be pregnant, we will require you take a pregnancy test.)
I will take a pregnancy test
A pregnancy test will be done in our office to confirm that you are not pregnant (cost is $20).
Initials
I refuse to take a pregnancy test because I am not pregnant
Initials
Patient Signature:*

Clear
Date:

MonthDayYear
Date
Time:

Hour Minutes

AM/PM Option
Witness Signature:

Clear
Date:

MonthDayYear
Date
Time:

Hour Minutes

AM/PM Option

Pharmacy Name:
Pharmacy Number:
Please enter a valid phone number.
Pharmacy Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list any allergies you have to any medication:
Please list all Herbal or Natural remerdies or Vitamins you take daily:
Do you use GooRx? If not please ask us about them.
Name:
Date of Birth:

MonthDayYear
Date
Please provide your photo I.D. so that Dr. Hennessy can e-scribe your prescriptions.
Photo ID File Upload (4MB limit)

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