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Consultation Intake Form
Thank you for choosing Dr. Giancarlo McEvenue Plastic Surgery!
Name
*
First Name
Last Name
Email
*
Confirmation Email
example@example.com
Phone Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Zip Code/Postal Code
*
Medical History
Current Weight
*
Lbs.
Height (in ft)
*
Please Select
4
5
6
7
Feet
( inches)
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
Inches
Please describe what you are looking for. This may include specific areas, body goals or things you want to enhance. The more information you provide to us the better.
*
Have you ever had surgery before?
*
Yes
No
Please provide details on previous surgical procedures
*
Do you take any medications?
*
Yes
No
Please list all medications you take
*
Include any herbal medicine, supplements, diet pills, etc.
Do you have any medication allergies?
*
Yes
No
Please list your allergies
*
Include any herbal medicine, supplements, diet pills, etc.
Do you have any medical conditions?
*
Yes
No
Check all medical conditions that you have
*
Anemia
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
History of Blood Clots
Malignant Hyperthermia
HIV
Other
Please Explain what other medical condition you have
*
Did you ever smoke nicotine cigarettes or vape?
*
Yes I currently smoke
I Quit smoking
Never smoked
Other
Please Provide more information on how long you smoked for and when you quit?
*
Have you or someone in your family ever had a Bloodclot?
*
Yes
No
Please provide more information on who/why/when of the bloodclot.
*
How Did you hear about us?
*
Previous Patient
Tik Tok
Instagram
Facebook
Google
Realself
Please upload your photos
*
Add photos
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Please include area you want to be evaluated: FRONT | LEFT SIDE | RIGHT SIDE| BACK. (Good lighting, no filters, face is not necessary to include for body procedures).
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Do you agree to transmit your information electronically to Dr. Giancarlo McEvenue?
*
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I agree
Dr.Giancarlo takes privacy very seriously and complies with HIPAA policies whenever possible. However many of the communications used today (emails, text, phone, web, social media, etc.) are not HIPAA compliant. By selecting "I Agree" I acknowledge, understand and accept that using these forms of communication it might not be fully compliant with all HIPAA regulations.
Do you agree to be contacted via SMS text message regarding your consultation request?
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We will never share, trade, or otherwise sell your personal information such as Phone numbers and SMS consent to third parties under any circumstances.
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