WELLNESS at Tulsa Surgical Arts

WELLNESS at Tulsa Surgical Arts

& Bella Roma Medical Spa
Which area of wellness are you interested in?
Will your consult be:
Patient Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race/Ethnicity
Marital Status
Occupation
Emergency Contact Name

First NameLast Name
Emergency Phone Number

Area CodePhone 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)
Are you pregnant? (Women)
Do you drink alcohol?
Are you smoking?
Are you taking any illicit drugs?
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.

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

Patient Information