Plastic Surgery Patient Form
Patient Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
Company Name
Emergency Contact Name
First Name
Last Name
Emergency Phone Number
-
Area Code
Phone Number
Health Insurance Policy Company
Policy ID
Insured Name
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 pregnant? (Women)
Yes
No
Do you drink alcohol?
Never
Occasionally
Daily
Do you drink coffee?
Never
Occasionally
Daily
Are you smoking?
Never
Occasionally
Daily
Are you taking any illicit drugs?
Never
Occasionally
Daily
Have you undergo 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
Asthma
1
2
Cancer
3
4
Chest pain
5
6
Chemotherapy
7
8
Diabetes
9
10
Heart Disease
11
12
Hepatitis
13
14
HIV
15
16
Kidney problems
17
18
Skin issues
19
20
Tuberculosis
21
22
Bleeding disorder
23
24
Psychiatric condition
25
26
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
2 digit month, 2 digit day, 4 digit year
Date
Physician Name
First Name
Last Name
Physician Signature
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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