WELLNESS at Tulsa Surgical Arts
& Bella Roma Medical Spa
Which area of wellness are you interested in?
Peptide Therapy
GLP-1 Weight-loss Therapy
Hormone Replacement Therapy
Unsure
Will your consult be:
In Person
Virtual
Patient Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race/Ethnicity
Marital Status
Occupation
Emergency Contact Name
First Name
Last Name
Emergency Phone Number
-
Area Code
Phone Number
Medical Conditions/Questions
Are you currently taking any medications? If yes, please list them below and provide the purpose and dosage.
Do you have any allergies? If yes, please list them below:
Are you planning to undergo cosmetic surgery in the next 6 months? (this does NOT deter you from therapies)
Yes
No
Are you pregnant? (Women)
Yes
No
Do you drink alcohol?
Never
Occasionally
Daily
Are you smoking?
Never
Occasionally
Daily
Are you taking any illicit drugs?
Never
Occasionally
Daily
Have you undergone any surgery before? If yes, please provide the surgery procedure's name, date, and reason.
Do you have a family history of any of the following? Please check the below, if none, then leave it blank.
Hypertension
Stroke
Heart Disease
Diabetes
Cancer
Anemia
Other
Medical History - Please select if you have a history of the following:
Rows
Yes
No
Cancer (active, past, under surveillance)
Blood Clotting, Stroke, or Unexplained Vascular Events
Autoimmune or Immune System Disorder
Endocrine Tumors, Hormone Sensitive Conditions
HIV
Kidney problems
Tuberculosis
Bleeding disorder
Psychiatric condition
Severe Allergic Reactions to injections, hormones, or biological therapies
How did you hear about us?
Facebook
Twitter
Instagram
YouTube
Online Advertisement
Google Search
Referred by a friend
Newspaper/Magazine
Other
Patient Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
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