Rapaport Plastic Surgery: Breast Enhancement Procedures Intake Form

Date and Time of Submission:*

Date

Hour MinutesAM/PM Option

Patient's First Name:*

Patient's First Name

Patient's Last Name:*

Patient's Last Name

Birthday [MM/DD/YYYY] :*

Birthday [MM/DD/YYYY] :

Gender: please mark the one that applies to you*

Gender: please mark the one that applies to you

Marital Status:*

Marital Status:

Address*

City*

State*

Zip.*

Home phone

Area CodePhone Number

Cell phone*

Area CodePhone Number

Email Address*

Do you prefer to be contacted via: Please mark all that apply*

May we leave you a message in your preferred method of communication?*

May we leave you a message in your preferred method of communication?

Employment Information:*

Employment Information:

Occupation:*

Please note, your occupation information may be shared with the hospital or healthcare providers if necessary for your care, but we will not contact your employer directly.

Employer or School Name:*

This information may be shared with the hospital or healthcare providers if needed for your care, but we will not contact your employer or school directly.

Work/School Address

City

State

Zip.

Work Telephone:

Spouse or Partner Contact Information: [First Name]

Spouse or Partner Contact Information: [Last Name]

Spouse or Partner Contact Information: [Cell phone]

Emergency Contact: [First Name]*

An emergency contact is required for all patients. Please provide the name and phone number of someone we can reach in case of an emergency.

Emergency Contact: [Last Name]*

An emergency contact is required for all patients. Please provide the name and phone number of someone we can reach in case of an emergency.

Emergency Contact: [Relationship to Patient]*

Emergency Contact: [Relationship to Patient]

Emergency Contact: [Preferred Telephone]*

Area CodePhone Number

How did you hear about us?*

Influencer's Referral Code/Promo Code

If Applicable

Can we follow you on instagram?

My Handle Is: @

If Applicable

Prior to today's visit have you ever had an aesthetic consultation including injectables or surgery? Please explain below.*

Prior to today’s visit have you ever had an aesthetic consultation including injectables or surgery? Please explain below

Is this your first medical aesthetic experience?*

Is this your first medical aesthetic experience?

Aesthetic Topic(s) Would You Like To Discuss*

Aesthetic Topic(s) Would You Like To Discuss

Have you consulted with other physicians about procedure(s) indicated above?*

Have you consulted with other physicians about procedure(s) indicated above?

Kindly provide details of any previous aesthetic surgeries along with the year performed (if applicable).*

If none, please write “None” or “N/A.”

Are you under any physician care at the present time? If so, please explain.*

Are you under any physician care at the present time? If so, please explain.

Do you currently use any of the following medications? (Ozempic®, Wegovy®, Mounjaro™, Other semaglutide alternatives)*

Do you currently use Ozempic®, Wegovy®, Mounjaro ™ or other semaglutide alternative?

If you are currently taking any of these medications, please indicate which one(s) you are using, the dosage (e.g., 0.5 mg, 1 mg, etc.), and how long you have been using them (e.g., 3 months, 6 months, etc.) in the space provided below.*

If you are currently taking any of these medications, please indicate which one(s) you are using, the dosage (e.g., 0.5 mg, 1 mg, etc.), and how long you have been using them (e.g., 3 months, 6 months, etc.) in the space provided below.

Please list any current prescription medication including: Birth control, Hormone replacement therapy, Diuretics, Weight loss drugs, Blood pressure or heart medication, Blood Thinners (i.e. Advil®, Aleve®, Excedrin®, Motrin®), Diabetes medication (Metformin), Tranquilizers, Sleeping pills, Pain medications, Herbal supplements (i.e. Vitamin E, Ginkgo, St John’s Wort, Ginseng)*

Please write "None" if you DO NOT take any medication(s) at this time.

Please list any non prescription medication including: supplements, over the counter medication, vitamins*

If you do not take any medications, vitamins, or supplements, please write "None" in the space provided.

Please list all allergies and describe reaction (i.e., Shellfish, Latex, Penicillin, etc.)*

If you have no allergies to medications, please write "None" in the space provided.

Have you ever had an anaphylactic (life threatening) reaction to a drug or product? Please explain*

If this question does not apply to you, please write "None" in the space provided.

Do you currently smoke? If yes, please specify the number of packs per day:*

If no, please write “No.”

Please specify the number of alcoholic drinks you consume per week:*

If you do not consume alcohol, please write “No.”

Do you use any other substances? (e.g., recreational drugs, cannabis, etc.)*

If you do not use any other substances, please write “No.”

Do you currently exercise? If yes, please provide details about your exercise routine. *

If no, kindly indicate 'no'.

Have you ever had a cold sore on your lips?*

Have you ever had a cold sore on your lips?

Do you have a history of cold sores?*

Do you have a history of cold sores?

Have you ever had problems with healing, abnormal scarring, skin color changes? Please explain.*

Height: _____ ft. _____ in.*

Height: _____ ft. _____ in.

Current weight: ______ lbs*

Current weight: ______ lbs

BMI (Body Mass Index):

If you're unsure of your BMI or do not have this information on hand, please feel free to leave this section blank. We'll calculate your BMI for you during your consultation

Preferred Pharmacy Name*

Preferred Pharmacy Name

Pharmacy Telephone*

Area CodePhone Number

Do you have any chronic medical conditions? Please check all that apply.*

If none apply, please write “None” or “N/A.”

Past Medical History*

If none, please write “No.”

Please list all prior surgeries, the year they were performed, and whether you experienced any complications.

If none, please write “No.”

Do you have a family history of blood clots or pulmonary embolism? If yes, please provide details.*

If no, kindly indicate 'no'.

Have you or anyone in your family ever experienced complications from anesthesia? If yes, please explain.*

If no, kindly indicate 'no'

Are you interested in hearing about our financing options?*

Are you interested in hearing about our financing options?

Reason for Breast Assessment:*

Reason for Breast Assessment:

Age:*

Age:

Sex:*

Sex:

Height: _____ ft. _____ in.*

Height: _____ ft. _____ in.

Current weight: ______ lbs*

Current weight: ______ lbs

Average weight range in the past 3 years ______ lbs*

Average weight range in the past 3 years ______ lbs

Female Patient’s # of Children__________

Age(s) of Child(ren)_____________

Did you breast feed your children?

If yes, for how long?

Do you smoke?*

If yes, how much and since when? Packs per day______ since __________

Do you have a history of Breast Cancer?*

Do you have a history of Breast Cancer?

If yes, please state year of Diagnosis:

If yes, have you received Hormone, Radiation therapy or Chemotherapy? Please specify

Do you have a personal history of cancer, or has anyone in your family been diagnosed with cancer?*

If Yes — Please specify type(s) and relationship(s): If No — Write “None”

Do you have a history of other forms of Cancer?*

If yes, please specify:

Do you have a family history of breast cancer?*

Do you have a family history of breast cancer?

If yes, please specify relationship and age of diagnosis:_______ at age _______

Do you have a history of any breast conditions and/or breast surgery?*

Do you have a history of any breast conditions and/or breast surgery?

If yes, please specify procedure and date:

What is the date of your last Mammogram? (If Applicable)*

What is the date of your last Mammogram? (If Applicable)

Which method of contraception/birth control are you currently using (if any)?*

Which method of contraception/birth control are you currently using (if any)?

Breast Assessment: Please fill this portion out to the best of your ability to help us understand your personal aesthetic goals. Current Cup Size:*

Current Cup Size:

Breast Assessment: Please fill this portion out to the best of your ability to help us understand your personal aesthetic goals. Desired Cup Size:*

Desired Cup Size:

If Breast Augmentation, which type of implant do you prefer?

Are you interested in learning about autologous fat transfer? Transplantation of fat from other body areas to breast(s)**

Are you interested in learning about autologous fat transfer? Transplantation of fat from other body areas to breast(s)*

What is your preferred positioning of implants? Please mark the one(s) that apply.

Which surgical approach do you prefer? Please mark the one(s) that apply.*

Which surgical approach do you prefer? Please mark the one(s) that apply.

Tell us: what are your greatest concerns regarding undergoing a breast procedure?*

Tell us: what are your greatest concerns regarding undergoing a breast procedure?

My most prominent aesthetic concern(s) is/are:*

My most prominent aesthetic concern(s) is/are:

(FACE) By Type of Concern: Please mark the one(s) that apply to you.*

(FACE) By Type of Concern: Please mark the one(s) that apply to you.

(BODY) By Type of Concern: Please mark the one(s) that apply to you.*

(BODY) By Type of Concern: Please mark the one(s) that apply to you.

(HAIR) By Type of Concern: Please mark the one(s) that apply to you.*

(HAIR) By Type of Concern: Please mark the one(s) that apply to you.

Are you interested in discussing about your personalized Daily Skincare regimen with our aesthetic skin experts?*

Are you interested in discussing about your personalized Daily Skincare regimen with our aesthetic skin experts?

Thank you for completing our Breast Enhancement Form & Cosmetic Questionnaire.

Your responses will be reviewed by a qualified provider to help develop a personalized treatment plan. This form provides essential information to tailor our recommendations for breast enhancement procedures that align with your aesthetic goals and unique needs. We are dedicated to delivering the highest standard of care and ensuring that you achieve the results you desire.

This document outlines the policies and agreements of Rapaport Plastic Surgery and COOLSPA/AETHOS [David P. Rapaport, MD, FACS] (together, the “Practice”) and applies to all patients receiving care at any Practice location.

The following information outlines our practice policies, financial terms, and your responsibilities as a patient. We kindly ask that you read this agreement in full. Your signature at the end confirms your understanding and acceptance of these terms.

1. Privacy & Confidentiality (HIPAA)

• My medical records will be maintained securely and in compliance with HIPAA and other applicable privacy laws.
• Records may be shared with other healthcare professionals involved in my care when appropriate.
• Photos and/or videos may be taken before, during, or after treatment for documentation and clinical purposes. These become part of my medical record.
• My information may be used for scheduling, billing, treatment planning, and internal quality improvement activities.
• The Practice may disclose my information to third parties (such as insurance providers or legal representatives) when required or permitted by law.
• Reasonable safeguards are in place to protect the privacy and confidentiality of my information.
• You may receive occasional marketing messages from the Practice. You may opt out at any time.

2. Financial Responsibility

• All fees are your responsibility and due at the time of service unless otherwise
arranged.
• If applicable, you must provide accurate insurance information. You are responsible for co-pays, deductibles, and services not covered. Pathology/bloodwork billing is handled by the laboratory. You are responsible for seeking any reimbursements.
• All payments for services and deposits are non-refundable.

3. Late Cancellation & No-Show Policy

At least 2 business days’ notice is required to cancel or reschedule any appointment. If notice is not provided, the following fees will apply:

• Complimentary consultations: $150
• Treatment appointments: $250
• Consultations with Dr. Rapaport: $250

4. Consultation Fee with Dr. Rapaport

• Consultation fee: $500
• Due: 2 business days prior to your appointment
• Policy: Non-refundable; may be applied toward any treatment within our practice for up to one year

5. Credit Card & Deposits

• A valid credit card is required to schedule all appointments, including those paid via gift card or designated as complimentary.
• Some services require a non-refundable scheduling deposit, which will be applied to your treatment.
• Third-party financing is not accepted for deposits.
• Your credit card information is securely stored for the purpose of reserving treatment pricing, holding your appointment date and time, and processing online purchases. Please bring your physical credit card to your appointment to settle any outstanding balances at the time of service.
• Authorization: I authorize the Practice and its providers to store and charge my credit card for any outstanding balances, including late cancellation or missed appointment fees.

6. Retail Policy

For retail items purchased from the Practice, I understand and agree to the following:

• All retail sales are final.
• Exchanges will only be issued for items that are defective or damaged.
• To request an exchange, I must notify the Practice within 30 days of the purchase date.
• Exchanges will be provided for the same product listed on the original purchase
receipt.
• In cases of allergic reactions, a doctor’s note confirming a clinical diagnosis is required to
request a refund, which is subject to office policy.

7. Consent to Treatment

• No guarantees or warranties have been made regarding the outcome of any procedures or
treatments.
• I understand that services provided by the Practice are voluntary, and I consent to proceed with
the care recommended to me.
• I have had the opportunity to ask questions about my care, and all questions have been answered
to my satisfaction.

8. Electronic Communication Consent

• I consent to be contacted by the Practice via phone, email, or text message for appointment reminders, billing notifications, and treatment-related communication. I understand that such communications may not be encrypted and waive claims for incidental privacy exposure.

9. Acknowledgment & Signature

By signing below, I confirm that:

• I have read, understood, and agree to this Patient Waiver, including the sections on privacy and financial responsibility.
• I have had the opportunity to ask questions, and any questions I had were answered to my satisfaction.
• I accept the terms and conditions outlined above.

Credit Card Authorization*

Credit Card AuthorizationI hereby authorize the Practice (Rapaport Plastic Surgery and COOLSPA/AETHOS [David P. Rapaport, MD, FACS]) to securely store my credit card information on file for the purpose of processing payments for any amounts owed, including outstanding balances and future charges related to treatments, products, or services. I understand that this information may be used for any future payments related to my account. I also acknowledge that I can update, modify, or remove my credit card details at any time by contacting the Practice. By signing below, I confirm that I am the authorized cardholder for the credit card provided and agree to the terms outlined above.

$0.50

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Date of Birth (DOB):*

Date of Birth (DOB)

Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code

By signing below, you acknowledge and consent to the secure storage of your credit card information by Rapaport Plastic Surgery and COOLSPA/AETHOS [David P. Rapaport, MD, FACS] (collectively, the "Practice") for future payments, as described above. This authorization will remain in effect until you provide new card information or withdraw your consent.

Name*

First NameMiddle NameLast Name

Date and Time of Submission:*

Date

Hour MinutesAM/PM Option

Authorization Signature*

Authorization Signature

Parent/Guardian Signature (If Patient is a Minor):

Patient Intake Forms

Patient Agreement Form