Patient Registration Today's Date (required) Patient's Name (required) Date of Birth(required) What is your present occupation? Gender MaleFemale Marital Status SingleMarriedOther Race WhiteBlackAsian Ethnicity Non Hispanic/LatinoHispanic/LatinoMiddle Eastern/IndianOther Address City State Zip Home Telephone # Cell Telephone # Email Address Medical Insurance Carrier Policy Number Subscriber Name Please indicate your interest(s) or reasons(s) for your consultation: Blepharoplasty-Eyelid LiftLip AugmentationBotox injectionsLiposuctionBreast EnlargementNeck LiftBreast LiftOtoplasty (Ear Pinning)Breast ReductionRhinoplasty (Nose)Brow LiftScar RevisionChin AugmentationSclerotherapy (Spider Veins)FaceliftSkin Care TreatmentsFacial PeelsTattoo RemovalRadiance InjectionsTummy tuckLaser Skin RejuvenationOther: Do you currently take any medications, including over the counter medications herbals or vitamins? Are you allergic to any medications? Do you smoke or chew tobacco? How much? How long? Do you drink alcohol? How much? How long? Do you take aspirin? How much? How long? Do you bleed easily? Do you bruise easily? Have you had any previous surgery? Is there a possibility you could be pregnant? Are there any illnesses that run in your immediate family? What is your Height? Weight? DO YOU HAVE ANY OF THE FOLLWING MEDICAL PROBLEMS Heart Disease YesNo High Blood Pressure YesNo Diabetes YesNo Thyroid Problems YesNo High Cholesterol YesNo Rheumatic Fever YesNo Heart Murmurs YesNo Stomach Problems YesNo Liver Problems YesNo Respiratory Problems YesNo Arthritis YesNo Seizures or Epilepsy YesNo Blood Disorders YesNo Cancer YesNo Anesthesia Problems YesNo Other I certify that the above information is complete and accurate. I am at least 18(eighteen) years of age, if not, I am accompanied by a parent/legal guardian. Patient's Signature x Date Parent/Legal Guardian's Signature x Date Do you authorize use to leave infomation regarding PHI, (lab results, radiology reports, biopsy results, appointment reminders, etc.) on an answering machine if you are unavailable? YesNo Contact Us! Fill out the form below and we will get back to you asap, thanks.
