Patient Intake Form
Please submit this form prior to your consultation with our office.
Patient Information
Name
*
First Name (required)
Middle Name
Last Name (required)
Date of Birth
*
/
Month
/
Day
Year
Birthdate
Email
*
example@example.com
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Social Security Number (Last 4 Digits)
Please enter a number less than or equal to 9999
Sex
*
Female
Male
Prefer not to say
Marital Status
*
Married
Widow
Divorced
Single
Florida Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Northern or Additional Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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ICE, Employment, & Payment Information
In Case of Emergency Contact
*
First Name
Last Name
In Case of Emergency Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer (Past or Present)
Are you retired?
Yes
No
Person Responsible for Payment
First Name
Last Name
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Medical History
As medical knowledge and experience continues to expand, there exists a risk of the specialist physician not being aware of the general health and medical background of a patient. Such information may critically affect what procedures we may safely perform and under what circumstances. We therefore ask that you give us the following medical information.
General Health
*
Good
Fair
Poor
Do you get regular physicals?
*
Yes
No
Date of most recent check up or physical
/
Month
/
Day
Year
Date
Have you had any recent weight changes or fluctuations?
*
Yes, from diet and exercise
Yes, from a weight loss medication
No
Height
Weight
Date of EKG
/
Month
/
Day
Year
Date
Please list any preexisting conditions, if any. If not, mark N/A.
*
Please list any past injuries, in particular those that resulted in a hospital stay. If not, mark N/A.
*
Any past surgeries?
*
Yes
No
If so, what kind of surgery?
Date of surgery
/
Month
/
Day
Year
Date
Were there any complications you experienced?
Include complications related to allergies, etc.
Consumption Levels
If not in use, write N/A.
Caffeine
*
Include amount and frequency
Tobacco
*
Include amount and frequency
Vape or Nicotine Product
*
Include amount and frequency
Alcohol
*
Include amount and frequency
Previous Ailments or Illnesses
Please select "Yes" indicating that you are currently or have ever been treated for, and "No" for never.
Tuberculosis
*
Yes
No
Cancer
*
Yes
No
Diabetes
*
Yes
No
Epilepsy or seizures
*
Yes
No
Heart disease
*
Yes
No
High blood pressure
*
Yes
No
Lung disease
*
Yes
No
Kidney disease
*
Yes
No
Blood disorder
*
Yes
No
Asthma
*
Yes
No
Mental conditions
*
Yes
No
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Consultation Questionnaire
How did you hear about us?
Seminar
Web Search
Previous Patient
Physician Referral
Naples Daily News
Gulfshore Life
Naples Illustrated
Other
What would you like to discuss with Dr. Prysi?
In which procedure(s) are you interested? (Check all that apply)
Face
Entire face
Mid-face
Lower face
Nose
Chin and jawline
Hooded eyes
Neck laxity
Med Spa
Chemical peels
DiamondGlow
Botox
Fillers
Skin resurfacing
Body
Liposuction
Tummy tuck
Thigh lift
Arm lift
Scar revision
Breast
Breast augmentation
Breast lift
Breast reduction
Implant revision
Gynecomastia
What specifically do you wish to have corrected?
*
i.e. what do you not like about...?
What is most important about your cosmetic procedure?
*
When did you start considering cosmetic procedures?
Why have you decided to have it done now?
Have you consulted another doctor about this? If so, when?
Have you discussed this procedure with your family?
Yes
No
Are they agreeable?
Yes
No
Do you understand that the objective of any cosmetic operation is improvement in appearance, not perfection?
Yes
No
Are you aware that the results of the operation might not fully meet your expectations?
Yes
No
Have you had previous cosmetic surgery?
*
Yes
No
If so, when and what was done?
If so, who performed the surgery and where?
Were you satisfied with the results?
If not, why?
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Patient Imaging Consent
In the course of consultation and discussion with Dr. Prysi, I may have been shown or may be shown or provided certain brochures, and/or pictures on an electronic computer imaging device. I understand that those pictures and alteration of those pictures seen are solely for the purpose of illustration/discussion and to provide improved communication with the doctor. I do understand that the outcome of any type of surgical procedure is directly related to my individual characteristics and health. I further understand and acknowledge that because of the obvious significant differences in how living tissue react to surgery, there may be no relationship between the electronic images created, and my actual final surgical result.Use of the computer imaging system offers an opportunity for me to discuss my desires and to allow an improved communication with the doctor.
Select 1 of the following
*
I hereby DO grant permission for the use of illustrations, photographs or imaging records created in my case for use in scientific and professional journals and presentations at any time during or after treatment, with complete confidentiality of my identity.
I hereby DO NOT grant permission for the use of any illustrations, photographs or imaging records created in my case for use in scientific and professional journals and presentations at any time during or after treatment, with complete confidentiality of my identity.
Signature
*
Witness Signature (if applicable)
Date
*
/
Month
/
Day
Year
Today's date
Submit
Submit
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