Patient Information
- Full Name: _________________________ Date: //___
- Date of Birth: //___ Age: ____ Gender: □ M □ F □ Other
- Address: ________________________________________________
- Phone: (Home) _____________ (Cell) _____________
- Email: ________________________________________________
- Emergency Contact: _________________ Phone: _____________
Insurance Information
- Primary Insurance: _____________________________________
- Policy Number: ________________________________________
- Secondary Insurance (if applicable): _______________________
Medical History
Current Medications
- List all medications, including supplements:
- _________________________ Dosage: _________________
- _________________________ Dosage: _________________
- _________________________ Dosage: _________________
Allergies
- □ No Known Allergies
- □ Yes (Please list): ____________________________________
Previous Surgeries
- Type: _______________________ Date: //___
- Type: _______________________ Date: //___
Specific Concerns
- Primary reason for visit: ________________________________
- Areas of concern: _____________________________________
- Previous cosmetic procedures: ___________________________
Medical Conditions
Please check all that apply:
- □ High Blood Pressure
- □ Diabetes
- □ Heart Disease
- □ Bleeding Disorders
- □ Autoimmune Conditions
- □ Other: ____________________________________________
Lifestyle Information
- Smoking Status: □ Never □ Former □ Current
- Alcohol Use: □ Never □ Occasional □ Regular
Consent
I certify that the above information is accurate and complete:
Signature: ______________________ Date: //___